Orthodontics and Craniofacial Research - Volume 4, Issue 2, May 2001

EDITORIAL
American perspective part II. Strategies for the survival of the species Todays orthodontist faces two options. The rst option is to do nothing and eventually become a general practitioner dentist, and the other is to be proactive in preserving the specialty. In the face of a serious shortage of educators there is not a third option. It is safe to assume that, given a choice, no orthodontist would like to relinquish his/her specialty status. What then are the preservation measures? The answer is simple: academia must be made attractive either for the residents of the United States or for potential immigrants, or both. People are happiest in an environment where they make a comfortable living, achieve the things they think are important and are recognized for those achievements. Who will make all of these happen? The dental school? Dental schools have neither a good track record of such deeds, nor any willingness to change that one can recognize. They have their own set of problems. The salvation, therefore, must come from within, obviously, in the form of an organization. The American Association of Orthodontists (AAO) along with its Foundation (AAOF) is in a position to make a difference. These two organizations can lobby to change the way an academic earns a living and to have the opportunity to advance the eld. Medical schools faced the faculty shortage problem long ago and were quickly able to institute an effective solution. For all intents and purposes, the medical school clinics today are faculty practices and the attendings earn commensurately per their busyness. At the same time, money for their activities of scholarship comes from those same clinics or from the associated foundations of various specialties. In contrast, the current scal model of a dental school is for the administration to claim the money generated in the orthodontic clinic, and in turn give a meager budget or handouts or favors to the department. A perhaps politically correct version of this model in some schools is where the administration has taken away the departments budget entirely, but the department keeps a portion of the clinical income. In either scenario, the
sum of money is small, and there are no funds for investment. No funds to pay the faculty satisfactory salaries, for investing in new faculty lines, or for investing in scholarly activities. In many schools, alumni contributions have kept the departments aoat, but in others, the administration takes even those funds away from the department. Generally speaking, the orthodontic department is the cash cow that supports the inactivity of other departments. Clearly, there would be no attraction for this arrangement in academia for any sane person where the pay is low and the obligation to carry the schools nancial burden is high. How can the AAO and AAOF help? The system must change. Dental schools must be run by administrators with entrepreneurial skills, and the scal power decentralized. It would be nave to expect any existing administration to make this change on its own volition. The change must come from the ofce of the President of the University and the Board of Trustees. The AAO must put signicant effort and money into lobbying these bodies. Perhaps such lobbying is needed even at the Congressional level. Lobbying is expensive, but no more expensive than not being a specialist. In the short term, AAOF funds are better spent for lobbying activities to preserve the specialty. During the period while this new order is taking place the orthodontic department could be augmented by imported academic personnel from abroad. Unfortunately, there is no such mechanism. At best in some states, the imported faculty member can teach in the clinic and have an intramural practice 1 day per week. The State Board of Dentistry must be lobbied to allow these faculty members to practice on a daily basis as long as they stay in academia full-time. Additionally, AAOF could provide matching funds for their retirement plans as well as portfolio management advice and services. There is ample expertise among the AAO to provide such support to the young academic, citizen or permanent resident. Investment of funds in these areas is what will ensure our survival as specialists. Not as a criticism, but rather as a statement of fact, it can be said the AAO has been preoccupied to address the needs of the
Clin Orthod Res 4, 2001/63642
63
Editorial
current membership at the expense of investments for the future of the specialty. The exceptionally well put together Practice Alternatives program, for example, is in place really to help the selling of current members practices. Similarly, the Council on Scientic Affairs, while trying to decide whom to award among the candidates, oftentimes nds itself trying to choose between the advancement of science and practical issues of today. Meanwhile, the Council on Informatics spends more time trying to help the current membership, rather than planning for the future, and there are identical stories told about the Council on Com-
munications or Education, or the rest. Obviously, the needs and interests of the current membership can never and must never be overlooked. Yet at the same time, room must be made for the future of the specialty. It will behoove all of us to support the AAOF to make these changes happen at the AAO level, Board of Trustees level and at the State Board of Dentistry level. Extinction is not an exciting practice alternative. Orhan C. Tuncay Editor-in-Chief
64 2Clin Orthod Res 4, 2001/6364
B Ahmed MS Gilthorpe R Bedi
Agreement between normative and perceived orthodontic need amongst deprived multiethnic school children in London
Authors affiliations: Bilal Ahmed, Faculty of Dentistry, Jinnah Medical and Dental College, Karachi, Pakistan Mark S. Gilthorpe, Biostatistics Unit, Eastman Dental Institute, University College London, UK Raman Bedi, WHO Collaborating Centre for Disability, Culture and Oral Health, Eastman Dental Institute, University College London, UK Correspondence to: Raman Bedi, BDS, DDPH, RCS, M.Sc. WHO Collaborating Centre for Disability Culture and Oral health Department of Transcultural Oral Health Eastman Dental Institute 256 Grays Inn Road London WC1X 8LD UK Tel: + 44 0 20 79152314/1193 E-mail: r.bedi@eastman.ucl.ac.uk
Dates: Accepted 4 December 2000 To cite this article: Clin. Orthod. Res. 4, 2001; 65 71 Ahmed B, Gilthorpe MS, Bedi R: Agreement between normative and perceived orthodontic need amongst deprived multiethnic school children in London Copyright Munksgaard 2001 ISSN 1397-5927
Abstract: The Index of Orthodontic Treatment Need (IOTN) has been used in dental epidemiology and to prioritize orthodontic treatment. The aim of this paper was to use the aesthetic component (AC) of the IOTN to measure agreement between normative and perceived orthodontic need amongst school children. Three hundred and seventy-eight children aged 11 14 years, enrolled in London UK state schools participated in this survey. The study focused on three ethnic groups: white, black and South Asian. Townsend deprivation scores suggested that the children were from areas of high socio-economic deprivation. Logistic regression analysis was carried out for agreement between normative and perceived need at each threshold value. Perceived need for braces, ethnic background, social class and hours of television viewing were signicant variables. Black pupils were signicantly less likely to concur on normative and perceived need scores, tending to perceive less need for treatment than did the dentist. Subjects from lower social classes were signicantly more likely to concur on normative and perceived need scores. In conclusion, the study showed that using the IOTN AC at various points along the scale, different inuences play a signicant role in agreement/disagreement between normative and perceived needs, indicating that patient clinician agreement regards orthodontic treatment is sensitive to several cultural factors.
Key words: ethnicity; IOTN; perceived orthodontic need
Ahmed et al. Orthodontic need amongst multiethnic children
Introduction
Professional dened orthodontic normative need and patients perceived needs are found to show poor correlation (1). Reasons for the differences have been elucidated by Shaw, suggesting that the dentist/orthodontist is more critical of their assessment of treatment need (1). Moreover, as patients commonly accept orthodontic treatment, a study into the factors associated with agreement between normative and perceived need would be of interest. The Index of Orthodontic Treatment Need (IOTN) was developed by Brook and Shaw (1989) (2) with a view of assessing treatment priority, and consequently, providing equitable treatment for those most in need. Richmond et al. (1995) used the aesthetic component (AC) of the IOTN to classify patients into three broad groups: no need for treatment, possible treatment need, and denite treatment needs (3). Although typically 10 photographs of the AC scale provide gradation of severity, this has come under criticism for measuring perceived need, as patients try to match their malocclusion to one of the 10 photographs and fail to use it as a scale (4). There is little published information on ethnic variations in orthodontic normative and perceived need in the UK. However, when satisfaction with orthodontic treatment is considered, research from North America indicates that there are few ethnic differences (5, 6). This study aims to examine agreement between orthodontic normative and perceived needs amongst school children from three different ethnic groups resident in London, UK. Furthermore, agreement is explored in relation to several other recorded factors, and this is explored for the entire range of thresholds along the IOTN AC scale.
Materials and methods

An orthodontic epidemiological survey was undertaken in April 1999 among 11 14-year-old children attending four state schools in North London. The schools were selected in order to ensure a wide cross-section of socio-economic and ethnic backgrounds. The aim of the survey was to assess the
childrens perception of their malocclusion and compare this with the assessment of a calibrated examiner (BA). The examiner had undergone a 3-day calibration programme for Peer Assessment Rating (PAR) and IOTN. He demonstrated specicity of 84.2% and sensitivity of 100%. Weighted Kappa was 0.82. The child was asked to show his/her teeth in centric occlusion and the calibrated examiner rated the malocclusion using the IOTN AC scale. The childs perception of their malocclusion was assessed using a self-administered questionnaire. A visual analogue scale was devised and explained to each child, it comprised of two pictures, IOTN AC 1 and 10, and it was explained to each child that these two pictures represented two extremes of a range 110. The children were asked to rate their own teeth. This approach avoided the problem of children matching their occlusion with one of the 10 IOTN AC pictures, as found by Burden and Pine (4). Demographic variables concerning gender, class, ethnic background, fathers occupation and postcode were also recorded. Other questions asked the child if they perceived that they needed braces (yes, no, do not know); importance of having straight teeth (very important, important, neutral, of little importance, unimportant); hours of television viewing per day (less than 1 h, 12 h, more than 2 h); and whether they perceived that the media affected their self-image (strongly agree, agree, neutral, disagree, strongly disagree). The Registrar General classication was used to record ethnic background. Postcodes in the UK correspond to areas that can be assigned deprivation scores, indicating socio-economic deprivation relative to England (7). To investigate the relationship between normative and perceived needs, logistic regression analysis was performed to measure agreement at each IOTN AC threshold. Those normative and perceived scores above and below the threshold that concurred were scored 1, those scores that disagreed at the threshold were scored 0. Fig. 1 shows an example using the IOTN AC 5 threshold. Each threshold (29) on the IOTN AC range was used for eight separate logistic regression analyses. Signicant variables at the 5% level were retained in the nal regression models for each threshold.
Fig. 1. Encoding normative and perceived need in a binary format where the shaded area represents agreement (1) and the unshaded disagreement (0). IOTN AC 5 threshold is used as an example in this diagram.
Results
The sample comprised 378 children, males representing 56%, and females 44%. To achieve sufcient numbers representative of each minority ethnic group, those children from black-Caribbean, black-African and black-other ethnic groups were amalgamated. Children from a South Asian background, for example Indian, Pakistani and Bangladeshi were also grouped.
Children from a mixed or Chinese background were excluded in the analysis because of the small numbers in the group (n= 55). Thus, three principal groups were formed: white, black and South Asian (Table 1). Townsend deprivation scores indicated that the children lived in areas of high social deprivation relative to the whole of England, with 63% of the study group from the lowest quintile (containing the 20% most deprived populations). A further 37% of the children were from the second lowest quintile. Using the Registrar General Classication of fathers occupation, 38% were classied as being from the higher social classes (I, II and III non-manual). When each IOTN AC score was, in turn, used as a threshold for agreement, different independent variables were found to be signicant at each threshold. Principally, perceived need for braces, hours of television viewing, ethnic background and social class were found to be signicant for varying thresholds. Table 2 shows signicant variables at each threshold and the odds ratio for each signicant variable. The p-value in the second column of Table 2 is of the overall contribution of the variable in the regression analysis and the p-value in the fourth column refers to the individual contrasts of each variable category. Fig. 2 shows a plot of the contribution of signicant regression variables for each IOTN AC threshold.
Table 1. Amalgamation of ethnic groups into white, black and South Asian
Ethnic group Frequency Percent Amalgamated ethnic group Amalgamated scores Percent
White Black-Caribbean Black-African Black-other Indian Pakistani Bangladeshi Chinese Other-Asian Other-other Total
100 60 44 13 84 21 1 4 24 27 378
26.5 15.9 11.6 3.4 22.2 5.6 0.3 1.1 6.3 7.1 100
? ? ?
White
100
30.9
Black
117
36.2
South Asian
106
32.8
Other
Excluded
323
100
67
Table 2. Logistic regression showing signicant variables in the model of agreement between normative and perceived IOTN AC scores at thresholds 29
IOTN AC grade Signicant regression variable (p -value)
Discussion
This study used the IOTN AC index for subject selfperception, allowing the subject to judge their occlusion from two pictures: IOTN AC 1 and 10. The examiner, having been calibrated in the use of IOTN and being familiar with different occlusal traits, had an advantage compared with the student, whom only had access to two pictures and had to make a judgement. Consequently, this study revealed some interesting ndings in terms of normative and perceived need agreement among children from different ethnic backgrounds. The IOTN AC scale was used effectively in mapping changes across the scale, from well-aligned teeth to severely mal-aligned teeth. This study did not assume any one particular cut-off for which agreement was important, but rather considered every IOTN cut-off for agreement between the subject and examiner. This problem was addressed by using a binary outcome, where outcome data in a logistic regression were entered either as 1 or 0, rather than in its original raw score. Raw scores could not be used, as the IOTN AC index does not exhibit a true interval scale. For instance, a score of 4 has not shown to be twice as severe as a score of 2. This approach gave an insight into how various independent variables were associated with agreement between normative and perceived needs across the entire scale. The signicant variables are as follows.
Response
p -value
Odds ratio
Braces (pB0.001)
Yes Do not know
0.001 0.170 0.001 0.001 0.265 0.002 0.002 0.523 0.006 0.113 0.001 0.550 0.001 0.004 0.001 0.530 0.001 0.090 0.011 0.023 0.045 0.011 0.024 0.860
8.70 3.40 6.60 2.40 3.20 4.50 2.40 1.20 0.44 0.61 0.46 0.83 0.23 0.36 0.37 1.20 0.25 0.46 2.10 0.23 0.24 2.10 0.18 1.20
Braces (pB0.001)
Yes Do not know
Television (p =0.008)
12 h 2+ h
Braces (p =0.006)
Yes Do not know
Ethnicity (p =0.024)
Black S. Asian
Ethnicity (p =0.020)
Black S. Asian
Braces (pB0.001)
Yes Do not know
Ethnicity (pB0.001)
Black S. Asian
Braces (pB0.001)
Yes Do not know
Perceived need for braces
Social class (p =0.011) 8 Braces (p =0.070)
Lower class Yes Do not know
Social class (p =0.029) 9 Braces (p =0.020)
Lower class Yes Do not know
Braces: perceived need for braces (do you think you need braces?): reference category: no. Ethnicity: white, black, South Asian: reference category: white. Social class: upper/lower class: reference category: upper class. Television: how many hours of Television do you watch per day: reference category: less than 1 h.
Desire for treatment showed a signicant nding, where at low thresholds (IOTN AC 2 4) subjects were 2 9 times more likely to agree, at higher levels (IOTN AC 6 9) subjects were 46 times less likely to agree. This was signicant with most of the respondents and the examiner agreeing with each other. At the low threshold, (AC scores 24) most of the cases are falling in the 410 range; hence agreement is high. For higher thresholds, (AC scores 69), cases tended to fall either above or below each threshold, and subjects were less likely to concur with the examiner. This is a very interesting nding that suggests that the examiner and subjects are scoring their dentition using different scales. The discrepancy could be in the use of the
scale, as the IOTN index was not initially designed for subject self-perception, but rather the aim was to develop a valid and reproducible index of orthodontic treatment priority (2). At IOTN AC 5 the impact of braces reverses from agreement to poor agreement, There is no signicant result in this category in the regression analysis at IOTN AC 5, indicating that, at the 5% level of signicance, this threshold showed no impact on agreement. This suggests that, at this threshold, the need for braces places the examiner and subjects at equipoise with regard to agreement on the need for orthodontic treatment.
Ethnicity
other factors affecting potential differences, black children perceive their dentition differently to white children when compared with a calibrated professionals score. The inuence of ethnicity was only signicant at the IOTN AC 4 6 range, but not for other scores. Why exactly this was is difcult to determine but warrants further research. The reasons for ethnic variations in agreement could relate to: (a) the use of the IOTN index and/or (b) morphological dento-facial differences in different ethnic groups.
The use of the IOTN index
Black children at certain thresholds of the IOTN AC scale (46) were less likely to concur with normative treatment need compared with white or South Asian children. This suggests that, after accounting for all
The IOTN scale was developed primarily on a white British population. Although no mention was made on the ethnic background of the subjects or judges in the development of the scale, it would not be unreasonable to presume the judges were of white ethnic origin to suit the index to the majority of children in the nation (2).
Fig. 2. Diagram to show signicant variables in the regression model across each IOTN threshold for agreement between normative and perceived need scores.
69
Morphological dento-facial differences
Arguably, IOTN AC is better suited to whites and South Asians, both of whom share similar dento-facial features. Blacks have a different cephalometric relationship and thus the IOTN AC scale may not be as well suited to them. There is overwhelming evidence to suggest that blacks generally have signicantly different types of occlusion compared to other ethnic groups. For example, they are more likely to have Class III occlusion, anterior open bites and mid-line diastema than their white or South Asian counterparts (8, 9), and more likely to have bimaxillary proclination (1012). In a large study conducted by Emrich et al. (1965), white children had Class II occlusion twice as frequently as black children, 15 and 7%, respectively (13).
are signicantly associated with agreement between normative and perceived needs. Although Richmond et al. (1995) classify IOTN AC score 4 as no treatment need, this study suggests that subjects feel the desire for treatment after this threshold (3). The use of the scale needs careful attention in terms of providing treatment on equitable grounds. Clinicians often focus on clinical indicators such as overjet, overbite and crowding/spacing etc., yet in the delivery of orthodontic care, agreement between clinician and patient is the pillar for compliance through therapy. However, this study reveals that such agreement is uid and may depend upon cultural and environmental factors that affect agreement differently at different thresholds of the IOTN AC scale.
Structured Abstract
Social class Authors Ahmed B, Gilthorpe MS, Bedi R. Background The relationship between self-perception of malocclusion and professional judgement has been amply investigated. The investigators concur that self-awareness and clinical status are poorly correlated. Objectives To use the Index of Orthodontic Treatment Need Aesthetic Component (IOTN AC) to measure agreement between normative and perceived orthodontic need at varying IOTN AC thresholds amongst 378 school children. Design A cross-sectional dental epidemiological survey. Setting and sample population Children aged 11 14 years, engaged in secondary education in state schools located in north London. The study focussed, principally, on three ethnic groups: white, black and South Asian. Townsend deprivation scores suggested that the children were from areas of high socio-economic deprivation. Logistic regression analysis was carried out for agreement between normative and perceived need at each threshold value. Results Perceived need for braces, ethnic background, social class and hours of television viewing were signicant variables in some models. Black pupils were signicantly less likely to concur on normative and perceived need scores, tending to perceive less need for treatment than did the dentist. Subjects from lower social classes were signicantly more likely to concur on normative and perceived need scores. Conclusion Using IOTN AC this study demonstrates that at various points along the scale, different inuences play a signicant role in agreement/disagreement between normative and perceived needs, indicating that patient clinician agreement regards orthodontic treatment is sensitive to several cultural factors.
Social class was a signicant factor, with children from lower social classes more likely to concur with normative need than higher social classes at IOTN AC 7 and 8. However, why this inuence was not signicant at other thresholds needs further investigation. Of importance is the fact that, according to the Townsend scores, most of the sample was from socio-economically deprived backgrounds. Hence, the inuence of social class should be interpreted with care.
Hours of watching television
Interestingly, at IOTN AC 3, subjects watching more than 2 h of television were more likely to concur on agreement. This nding could be artefactual in that, at such a low threshold, the majority of cases on agreement fall above this threshold. Nevertheless, this result suggests that, in relation to levels of media exposure, there are possible differences in agreement across the lower values of the IOTN AC scale.
General implications
Using IOTN AC, this study demonstrates that, for various points along the scale, different inuences
Clinical Orthodontics and Research 4, 2001; 65 71 Copyright Munksgaard 2001, ISSN 1397-5927
Acknowledgements: We would like to thank Carole Brown for arranging school visits and Sue Cunningham for her input on this article.
References
1. Shaw WC, Lewis HG, Robertson NRE. Perception of malocclusion. Br Dent J 1975;138:2116. 2. Brook PH, Shaw PC. The development of an index of Orthodontic Treatment Priority. Eur J Orthod 1989;11:309 20. 3. Richmond S, Shaw WC, OBrien KD, Buchanan IB, Stephens CD, Andrews M, Roberts CT. The relationship between the Index of Orthodontic Treatment Need and consensus opinion of a panel of 74 dentists. Br Dent J 1995;178(10):370 4. 4. Burden DJ, Pine CM. Self-perception of malocclusion among adolescents. Community Dent Health 1995;12:89 92. 5. Sheats RD, McGorray SP, Keeling SD, Wheeler TT, King GJ. Occlusal traits and perceptions of orthodontic need in eight grade students. Angle Orthod 1998;68(2):10714.
6. Searcy VL, Chisick MC. Perceived, desired and normatively determined orthodontic treatment needs in male US army recruits. Comm Dent Oral Epidem Dec 1994;22(6):43740. 7. Townsend P, Davidson N, Whitehead M, editors. Inequalities in Health. Harmondsworth: Penguin; 1992. 8. Trottman A, Elsbach HG. Comparison of malocclusion in pre-school black and white children. Am J Orthod 1996;110:69 72. 9. Brunelle JA, Bhat M, Lipton JA. Prevalence and distribution of selected occlusal characteristics in the US population, 1998 1991. J Dent Res 1996;75:706 13. 10. Carter NE, Slattery DA. Bimaxillary proclination in patients of Afro-Caribbean origin. Br J Orthod 1988;15:175 84. 11. Lavelle CLB. A study of multiracial occlusions. Community Dent Oral Epidemiol 1976;4:38 41. 12. McLain JB, Prott WR. Oral health status in the United States: prevalence of malocclusion. J Dent Ed 1985;49:38691. 13. Emrich RE, Brodie AE, Blayney JR. Prevalence of Class I, Class II, and Class III malocclusions (angle) in an urban population: an epidemiological study. J Dent Res 1965;44:1947.
71
RA Tanzilli RH Tallents RW Katzberg S Kyrkanides ME Moss
Temporomandibular joint sound evaluation with an electronic device and clinical evaluation
Authors affiliations: R. A. Tanzilli, Department of Dentistry, Division of Orthodontics, University of Rochester, University of Rochester Eastman Dental Center, Rochester, NY R. H. Tallents, Divisions of Orthodontics and Prosthodontics, Program Director Temporomandibular Joint Disorders, University of Rochester, University of Rochester Eastman Dental Center, Rochester, NY R. W. Katzberg, University of California at Davis Medical Center, Sacramento, CA S. Kyrkanides, Department of Dentistry, Division of Orthodontics, University of Rochester Eastman Dental Center, Rochester, NY M. E. Moss, Department of Dentistry, Oral Sciences, University of Rochester Eastman Dental Center, Rochester, NY Correspondence to: Ross H. Tallents, DDS 1333 Lake Avenue Rochester, NY 14613 USA Fax: + 1 716 244 8772 E-mail: Rosst@frontiernet.net
Abstract: Sound analysis to diagnose internal derangement has received much attention as an alternative to radiographic examination. The purpose of this study was to compare ndings with an electronic device (sonography) and clinical examination to magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ). Twenty-three symptomatic patients (46 joints) were evaluated for this study. All patients had jaw joint pain and one or more of the following ndings; limitation of jaw opening, painful mandibular movement with or without clicking or crepitation. The presence or absence of joint sounds was evaluated clinically by palpation and auscultation and with sonography. If sounds were present (clicking or crepitation) on either examination the patient was considered positive for disc displacement for that examination. Two by two tables were constructed comparing sonography and clinical examination with MRI ndings. The sensitivity of the sonogram was 84% and the specicity was 33% when compared with MRI ndings. The sensitivity of the clinical examination was 70% and the specicity was 40% when compared with MRI ndings. This study suggests that clinical and sonographic examination has a high sensitivity (low false negative examinations) but low specicity (high false positive examinations). Key words: comparative study; electronic devices; joint
Dates: Accepted 12 December 2000 To cite this article: Clin. Orthod. Res. 4, 2001; 72 78 Tanzilli RA, Tallents RH, Katzberg RW, Kyrkanides S, Moss ME: Temporomandibular joint sound evaluation with an electronic device and clinical evaluation Copyright Munksgaard 2001 ISSN 1397-5927
sounds; magnetic resonance imaging; temporomandibular joint disorders
Introduction
Clicking and crepitation are the most common temporomandibular joint (TMJ) sounds. Sound events occur as a result of alterations in tissue morphology and
Tanzilli et al. TMJ sounds
function, such as local thickening of the articular surface layers, macroscopic remodeling, deviations in condylar form and disc displacement (DD) (14). Arthrographic, morphologic and surgical ndings have supported the concept that most clicking sounds are associated with anterior DD with reduction (DDR) (5 11). The action of the condyle passing under the deformed posterior band, hitting the disc and temporal component has been suggested to be the most frequent cause of the sound (3, 4). The passage of the condyle beyond the articular tubercle and perforation of the disc may be other sources of sound events (12). Crepitation (grating or grinding sounds) has been considered an indication of a more advanced joint disease such as degenerative arthritis (DJD) (13). TMJ sound analysis to diagnose internal derangement has received much attention as a possible noninvasive, easily obtainable alternative to radiographic methods (14 16). Clinicians have attempted to assign an acoustical signature to TMJ sound analysis (14 16, 21). A recent review suggested there is inadequate evidence to support the use of sound analysis to evaluate TMJ internal derangement (18). Attempts to use joint propagated sounds to diagnose the various stages of internal derangement have been considered (1, 2, 14 16, 19, 22 24). Clinical studies have been performed to evaluate sounds for comparison to joint status (25 27), to monitor sounds during treatment (28) and to evaluate observer agreement (29). Some investigators feel that TMJ sounds in the non-patent are considered to be normal and not a manifestation of subclinical problems (30). They also feel that joint sound characteristics do not yet offer a solid basis for inferences concerning the development of TMJ abnormalities in the clinical setting (31). The purpose of this study was to evaluate patients presenting with localized jaw joint pain for the presence or absence of sounds recorded with an electronic device and clinical examination. The results were compared with magnetic resonance imaging (MRI) of the TMJ for the presence or absence of DD.

Twenty-three consecutive symptomatic patients with localized jaw joint pain on one or both sides were evaluated in this study. All patients had jaw joint pain
and one or more of the following ndings: limitation of jaw opening, painful mandibular movement with or without clicking, or crepitation. The presence or absence of joint sounds was evaluated clinically by palpation and auscultation and with the Sonopak (Bio-Research Inc., Milwaukee, WI). If sounds were present (clicking or crepitation) on either examination (palpation and auscultation), the patient was considered positive for DD for that examination. One joint from 10 patients, selected at random, was recorded ve times at 5 min intervals. Correlation coefcients were calculated for these examinations based on the absence or presence of sounds for the ve recordings. The correlation coefcient was calculated at 0.90. The clinical examination was performed by one investigator and immediately after this exam the electronic sound recordings were recorded by a second investigator without the knowledge of the ndings from the clinical examination. They were tabulated on separate exam records for later comparison. The Sonopak system was employed to record and analyze the joint sounds. Sounds were recorded bilaterally with two separate miniature vibration transducers mounted on a common headband. The frequency response of the transducer was 50420 Hz. The transducers were placed on the zygomatic process of the temporal bone over the joint, to minimize any motion artifacts from jaw and skin movement. A graphic jaw tracking device recorded the temporal relationship of the joint sounds and jaw movement. The unit output, a voltage that was digitized with a 9-bit Audio to Digital (AD) converter, was stored on a 486 computer for later analysis. The system has the ability to record at four gains (1, 2, 5 and 10). This allows the recording of sound events at varying sensitivities so as not to overload the system ampliers and produce harmonic resonance. The patient sat upright in a chair with no head support and a single open and close cycle was performed for three separate trials at all gains where there was identiable sound. Sound was identied by the software as a 15-point change in the AD conversion which is sufcient amplitude to distinguish a sound from the background noise. When there were no detectable sound recordings, gains 1 and 2 were always performed to be positive there were no sound events.
73
All patients had bilateral high resolution MRI scans in the sagittal (closed and opened) and coronal (closed) planes to evaluate the TMJs for the presence or absence of internal derangement (7, 8, 10, 11). The subjects were classied as normal (no internal derangement, N) or having DD [DDR, DD without reduction (DDN) with or without degenerative joint disease (DDN/DJD)] as described previously (7, 8, 10, 11). Data were collapsed into two groups based on magnetic resonance ndings: 1) symptomatic with normal disc position and 2) symptomatic with DD (DDR, DDN, DDN with DJD). Two by two tables were constructed based on the presence or absence of DD. The tables were constructed listing true positives (TP), false positives (FP), true negatives (TN) and false negatives (FN). Sensitivity (TP/TP +FN) and specicity (TN/TN + FP) were then calculated. The sonography and clinical examination ndings were compared with magnetic resonance ndings.
The clinical examination (Table 1) demonstrated that there were six normal joints (40%) that had no sounds and nine (60%) that had sounds. Five patients with DDR (36%) had no sounds and nine (64%) had sounds. Four patients with DDN (29%) had no sounds and 10 (71%) had sounds. The three (100%) DDN/DJD patients all had sounds. Tables 2 and 3 represent the two by two tables constructed for the calculations of the sensitivity and specicity. The sensitivity of the Sonopak examination was 84% and the specicity was 33% when compared with MRI ndings. The sensitivity of the clinical examination was 70% and the specicity was 40% when compared with MRI ndings.
Discussion
The use of imaging of the TMJ has increased over the last 1015 years. The use of electronic devices to evaluate and quantify sound events from the TMJ has been suggested as an economic alternative. Sounds were rst recorded by Ekensten (20) in 1952. He evaluated joint sounds in 30 patients on an oscilloscope and noted the variability of wave patterns. Ouellette (21) used a cassette recorder and an audio frequency analyzer and suggested the existence of four specic sound groups. He suggested that coarse, irreg-
Results
Twenty-three symptomatic patients (46 joints) were evaluated for the presence or absence of joint sounds with a clinical examination and an electronic recording device. There were 17 females (age=29.5, SD= 7.5 and six males (age= 32.1, SD= 9.5). Thirty-three percent of the joints (15) were normal, 30% (14) were DDR, 30% (14) were DDN and 7% (3) were DDN/DJD. (Table 1). The sonopak examination (Table 1) revealed that ve of the normal joints (33%) had no sounds and 10 (66%) had sound. Three patients with DDR (21%) had no sounds and 11 (79%) had sounds. Two patients with DDN (15%) had no sounds and 12 (85%) had sounds. The three (100%) DDN/DJD patients all had sounds.
Table 2. Comparison of Sonopak to MRI ndings. The sensitivity is 84% (26/26+5) and the specicity is 33% (5/5+10)
MRI+ MRI
Sonopak+ Sonopak
26 5
10 5
Table 1. The presence (yes) or absence (no) of sounds with the Sonopak and clinical examination for joints with normal (N), DDR, DDN and DDN/DJD ndings with MRI
N N DDR DDR DDN DDN DDN/DJD DDN/DJD
No Sonopak Clinical 5 6
Yes 10 9
No 3 5
Yes 11 9
No 2 4
Yes 12 10
No 0 0
Yes 3 3
Table 3. Comparison of clinical examination to MRI ndings. The sensitivity is 70% (21/21+9) and the specicity is 40% (6/6+9)
MRI+ MRI
Clinical exam+ Clinical exam
22 9
9 6
ular, sudden emphatic events of shorter duration compared with those of the asymptomatic volunteer, characterized the joint sounds of the symptomatic patient. He felt the sonogram was reproducible from one recording to the next and that most individuals would have a reproducible pattern. Watt (22) used a mingograph recorder and stereostethoscope to evaluate sounds made by 110 patients. A classication of joint noise based on the nature, quality and timing of these sounds was proposed. He suggested that hard (cracking) clicks were of shorter duration than those of soft (popping) clicks. Acoustical patterns have been evaluated in other joints. Chu et al. (24) indicated that acoustical analysis is a useful method of evaluating articular cartilage disease in knee joints. They suggested that there are distinct acoustical patterns for rheumatoid arthritis, DJD and normal knees that are distinctive. Various authors have attempted to place acoustical signatures for the sounds produced by internal derangement (14, 15, 17). The current literature is divided on this subject. Oster et al. (17) proposed that the ability to depict TMJ sounds in a quantitative manner might allow staging of the severity of the mechanical dysfunction. Hutta et al. (15) evaluated the differences of TMJ sounds between the different categories of internal derangement. They suggest that sound analysis may provide a sensitive and accurate non-invasive tool for diagnosis of the presence or absence of internal derangement with power spectrum analysis. This quantitatively examines the distribution of sound energy as a function of sound frequency. The resulting power spectra were used to quantitatively compare TMJ sounds among specic internal derangements. Peak frequency, the degree of smoothness and number of energy peaks present in the sound event were proposed to be predictive of specic types of DD. They suggested that DDR had a single peak near 100
Hz and a relatively smooth appearance. Seventy-one percent of joints with DDR were smooth compared with only 10% of the SN (symptomatic normal joints) and 5% of joints with DDN. Gay and Bartolami (2) indicate that TMJ disorders share signicant common spectral properties. Differences are neither characteristic nor reproducible and, therefore, have limited application in the differential diagnoses of internal derangement. Heffez and Blaustein (15) and Oster et al. (17) feel that the ability to depict TMJ sounds as a specic frequency pattern may provide an acoustical signature for predicting the type of DD. TMJ sounds seem to be a common nding in asymptomatic patients. The diagnosis of DD solely from clinical ndings has been questioned (24). The use of electronic devices might enhance our ability to predict the presence of DD. This study evaluated 23 patients (46 joints) with MRI, sonography and clinical examination (Table 1). Seventy-eight percent (36/46) of these joints displayed a signicant sound event with sonography. Seventy-two percent (26/36) of the joints with sound had conrmed DD while 28% (10/36) of the joints with sound events had normal disc position when evaluated with MRI. Widmalm et al. (25) studied 27 fresh autopsy specimens and found that joint sounds, such as clicking and crepitation, occurred only in joints with disc dysfunction and/or arthritic changes of the articular surfaces. They were not able to produce joint sounds in joints with normal disc position or normal articular surfaces. They suggest that all joint sounds indicate joint abnormality but the absence of sound does not indicate the absence of DD. This study suggests that the electronic device identied sound in 10 joints with normal disc position (Table 1). The disagreement between the two studies may be explained by the fact that the acoustical patterns of cadaver specimens may not the same. In studies of TMJ sounds, clinical variability is often a major concern. Eriksson et al. (26) reported that both the degree of DD or the degree of disc deformation in the TMJ cannot be diagnosed from clinical examination and that interobserver reliability is poor. Remington et al. (27) demonstrated considerable variability between subjects who all had reciprocal clicking but were otherwise asymptomatic. However, they had no
75
documentation of the staging of the internal derangement. Tallents et al. (28) and Roberts et al. (24) noted not all patients with clicking sounds had DD with reduction. Rohlin et al. (19) examined 55 TMJ autopsy specimens and found that 1/3 of the silent joints did indeed have anterior DD. In a clinical/arthrographic study by Roberts et al. (24) the problems of clinical examination can be observed when 72 patients suspected to have DDR were evaluated. Six had normal joints, 13 had DDN and 53 had DDR. They also found that 18% of symptomatic patients with the arthrographic diagnosis of DDR had no joint sounds on clinical examination. These results suggest that the clinical examination is awed and that the presence or absence of sounds is not as clinically diagnostic as one might expect. In this study clinical examination revealed 31 of 46 (67%) of joints had sound events (Table 1). Sounds were identied in 22 of 31 (71%) with DD and nine of
31 (29%) normal joints (Table 1). Roberts et al. (24) found that 15% of symptomatic patients with normal joints had clicking sounds suggestive of DDR on clinical examination. Clinical examination suggested that 40% (six of 15) of the normal, 36% of the DDR (ve of 14) and 29% of the DDN (four of 14) joints were silent. These values are similar to previous studies (24, 28). The major problem with sonography is the high number of false positive examinations (specicity = 33%). Clinical examination shares the same problems (specicity = 40%). Fig. 1 shows the sonographic examination of a patient that had a clicking event (left side). There were no audible or palpable sounds at clinical examination. This would represent a false positive sonographic examination because the subject had bilateral normal joints on MR examination. This would suggest that if an electronic device or clinical examination was used for the screening of patients and or volunteers, a signicant number of
Fig. 1. (A C) Patient with a clicking sound with a sonographic examination. This would represent a false positive sonography because the subject has bilateral normal joints with MR examination. (A) The right and left sound tracks (S-RT, S-LT), the vertical (Vert), anteroposterior (Ap) and right and left lateral (R,L). (B) The time domain wave form from the sound event. (C) Spectral frequency analysis, which suggests a peak frequency of about 120 Hz.
subjects might be over or under diagnosed as having a normal joint or a joint with DD. Sonography is good for the evaluation of joints with DD (sensitivity of 84%) because there were only ve false negative examinations. Tallents et al. (12) in a study of asymptomatic volunteers, with negative clinical examination, found that two of 16 (13%) subjects with DD did not have recordable joint sounds with vibration transducers. There were 44% of the joints that had identiable sounds, yet only 16% of the joints had DD. One-half of the sounds occurred at the apex of the articular eminence, which leaves 22 joints that might be suspected to have DD. If only 16 joints had DD then six had unexplained sound events. This suggests that evaluation of sound events in volunteers with no audible joint sounds for occult derangements will have a high number of false positive examinations. The present study in symptomatic patients suggests a high prevalence of false positive sonographic and clinical exams (Tables 2 and 3 specicity =33 and 40%, respectively). Sonopak picked up 6 15% more sound events than the clinical examination. Eriksson et al. (29) had 22 dentists and dental students listen to tape recordings of TMJ sounds. They classied their observations as no sound, clicking or crepitation. The observer agreement was low, with only 14% of the patients classied the same. This indicates that these clinical signs are not as objective as previously thought. It might be suggested that electronic recordings of joint sounds might offer an advantage in that it would detect sounds that might not be perceived by the human ear or by palpation. Electronic recording and storage of joint sounds would appear to offer several advantages over palpation or auscultation. There is the potential to store and compare observations at different times (change over time). There could be elimination of differences in the hearing and perception of the observer. This would make objective documentation of the sound and its character less variable as suggested be the study of Eriksson et al. (29). Unfortunately, there are many false positive examinations. If the initiation of treatment were based solely on sound events then a small number of patients would be treated inappropriately. If more invasive treatment is contemplated MRI imaging should be performed to substantiate the clinical and or sonographic diagnosis.
Conclusions
This study evaluated joint sounds in symptomatic TMD patients. Approximately 75% of the time, joint sounds were associated with DD. The absence of joint sounds did not exclude DD. Half of these silent joints had DD. Sonography has a good sensitivity (picks up sound events from symptomatic joints with DD) but the specicity (suggests DD when absent) is low.
Structured Abstract
Authors Tanzilli RA, Tallents RH, Katzberg RW, Kyrkanides S, Moss ME. Objective The purpose of this study was to compare ndings with an electronic device (sonography) and clinical examination to MRI of the TMJ. Study design Twenty-three symptomatic patients (46 joints) were evaluated for this study. All patients had jaw joint pain and one or more of the following ndings; limitation of jaw opening, painful mandibular movement with or without clicking or crepitation. The presence or absence of joint sounds was evaluated clinically by palpation and auscultation and with sonography. If sounds were present (clicking or crepitation) on either examination the patient was considered positive for DD for that examination. Two by two tables constructed comparing sonography and clinical examination to MRI ndings. Results The sensitivity of the Sonogram was 84% and the specicity was 33% when compared with MRI ndings. The sensitivity of the clinical examination was 70% and the specicity was 40% when compared with MRI ndings. Conclusions This study suggests that clinical and sonographic examination has a high sensitivity (low false negative examinations) but low specicity (high false positive examinations).
References
1. Gay T, Bertolami CN. The acoustical characteristics of the normal temporomandibular joint. J Dent Res 1988;67:5660. 2. Gay T, Bartolami CN. The spectral properties of temporomandibular joint sounds. J Dent Res 1987;66:1189 94. 3. Isberg-Holm AM, Westesson P-L. Movement of disc and condyle in temporomandibular joints with clicking: an arthrographic and cineradiographic study on autopsy specimens. Acta Odontol Scand 1982;40:151 64. 4. Isberg-Holm AM, Westesson P-L. Movement of disc and condyle in temporomandibular joints with and without clicking: a high speed cinematographic and dissection study on autopsy specimens. Acta Odontol Scand 1982;40:16577. 5. Dolwick MF, Riggs RR. Diagnosis and treatment of the internal derangements of the temporomandibular joint. Dent Clin North Am 1983;27:561 72.
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6. Sanchez-Woodworth RE, Tallents RH, Katzberg RW, Guay JA. Bilateral internal derangements of temporomandibular joint: evaluation by magnetic resonance imaging. Oral Surg Oral Med Oral Pathol 1988;65:2815. 7. Katzberg RW, Westesson PL, Tallents RH, Anderson R, Kurita K, Manzione JV, Totterman S. Temporomandibular joint: magnetic resonance assessment of rotational and sideways disc displacements. Radiology 1988;169:7418. 8. Westesson PL, Katzberg RW, Tallents RH, Sanchez-Woodworth RE, Svensson SA. Temporomandibular joint: comparison of MR images with cryosectional anatomy. Radiology 1987;164:59 64. 9. Bronstein SL, Tomasetti BJ, Ryan DE. Internal derangements of the temporomandibular joint: correlation of arthrography with surgical ndings. J Oral Surg 1981;39:57284. 10. Westesson PL, Rohlin M. Diagnostic accuracy of double contrast arthrotomography of the temporomandibular joint. Correlation between arthrography and morphology of autopsy specimens using dissection and cryosectioning. Swed Dent J 1982;11(Suppl 13):1 21. 11. Tasaki MM, Westesson PL. MR imaging of the temporomandibular joint: diagnostic accuracy with sagittal and coronal images. Radiology 1993;186:723 9. 12. Tallents RH, Hatala MA, Westesson PL, Katzberg WR, Murphy W, Proskin H. Temporomandibular joint sounds in asymptomatic volunteers. J Prosthet Dent 1993;69:298 304. 13. Hansson T, Nilner M. A study of the occurrence of symptoms of diseases of the temporomandibular joint masticatory musculature and related structures. J Oral Rehabil 1975;2:313 24. 14. Heffez L, Blaustein D. Advances in sonography of the temporomandibular joint. Oral Surg Oral Med Oral Pathol 1986;62:486 95. 15. Hutta JL, Morris TW, Katzberg WR, Tallents RH, Espeland MA. Separation of internal derangements of the temporomandibular joint using sound analysis. Oral Surg Oral Med Oral Pathol 1987;63:151 7. 16. Christensen LV, Orloff J. Reproducibility of temporomandibular joint vibrations (electrovibratography). J Oral Rehabil 1992;19:253 63. 17. Oster C, Katzberg RW, Tallents RH, Morris T, Bartholomew J, Miller T, Hayakawa K. Characterization of temporomandibular joint sounds: a preliminary investigation with arthrographic correlation. Oral Surg Oral Med Oral Pathol 1984;58:10 6.
18. Widmer CG. Temporomandibular joint sounds: a critique of techniques for recording and analysis. J Craniomandib Disord Facial Oral Pain 1989;3:213 7. 19. Gay T, Bertolami CN, Donoff RB, Keith DA, Kelly JP. The acoustical characteristics of the normal and abnormal temporomandibular joint. J Oral Maxillofac Surg 1987;45:397407. 20. Ekensten B. Phonograms of abnormalities of the temporomandibular joint in motion. Odont T (Scan J Dent Res) 1952;60:235 42. 21. Ouellette PL. TMJ sound prints: electronic auscultation and sonographic audiospectral analysis of the TMJ. JADA 1974;89:623 8. 22. Watt DM. Temporomandibular joint sounds. J Dent 1980;8:119 27. 23. Chu ML, Gradisar IA, Railey MR, Bowling GF. Detection of knee joint diseases using acoustical pattern recognition technique. J Biomechanics 1976;9:111 4. 24. Widmalm SE, Westesson PL, Brooks SL, Hatala MP, Paesani D. Temporomandibular joint sounds: correlation to joint structure in fresh autopsy specimens. Am J Ortod Dentofac Orthop 1992;101:60 9. 25. Roberts CA et al. Clinical and arthrographic evaluation of temporomandibular joint sounds. Oral Surg Oral Med Oral Pathol 1986;62:373 6. 26. Eriksson L, Westesson P-L. Clinical and radiological study of patients with anterior disc displacement of the temporomandibular joint. Swed Dent J 1983;7:55 64. 27. Tallents RH, Katzberg WR, Miller TL, Manzione JV, Macher DJ, Roberts D. Arthrographically assisted splint therapy: painful clicking with a non-reducing meniscus. Oral Surg Oral Med Oral Pathol 1985;61:2 4. 28. Remington KJ, Sadowsky C, Muhl ZF, Begole EA. Timing and character of reciprocal temporomandibular joint sounds in an asymptomatic orthodontic sample. J Craniomandib Disord Facial Oral Pain 1990;4:21 9. 29. Eriksson L, Westesson PL, Sjoberg H. Observer performance in describing temporomandibular joint sounds. J Cranimand Prac 1987;5:32 5. 30. Wabeke KB, Spruijt RJ, van der Weyden KJ, Naeije M. Evaluation of a technique for recording temporomandibular joint sounds. J Prosthet Dent 1992;68:676 82. 31. Spruijt RJ, Wabeke KB. An extended replication study of dental factors associated with temporomandibular joint sounds. J Prosthet Dent 1996;75:388 92.
PH Schiffman OC Tuncay
Maxillary expansion: a meta analysis
Authors affiliations: Patricia H. Schiffman, Department of Plastic and Reconstructive Surgery, Childrens Hospital of Philadelphia Orhan C. Tuncay, Department of Orthodontics, Temple University, School of Dentistry, Philadelphia Correspondence to: Patricia H. Schiffman, DMD, MS Department of Plastic and Reconstructive Surgery Childrens Hospital of Philadelphia The Wood Building Philadelphia, PA 19004, USA Fax: + 1 215 5902496 E-mail: schiffman@email.chop.edu
Abstract: The utility of maxillary expansion has been equivocal for more than 100 years. The advent of meta-analysis and evidence-based learning has provided an opportunity to look objectively at this treatment modality. Medline was searched from 1978 to 1999 for all studies examining the stability of transverse expansion of the human maxilla using initial search terms of maxillary expansion and palatal expansion which were limited to those English language and human subjects. The more than 5000 articles were reduced to 12 based on the dened inclusion and exclusion criteria. The two investigators participating in the study were blinded, the studies authors and origins blacked out and the evaluation coded and scored. A cumulative Meta evaluation score was computed for each study. Six studies remained for the nal analysis. The mean expansion after adjustment according to the principles of meta analysis was 6.00 mm with a standard deviation of 1.29 mm. Of the 6-mm average, 4.89 mm was retained while wearing retainers. Five of the papers provided retention data and post-retention data, but only three studies provided both retention and post-retention data. The average age of patients in these reports was 10.8 years. The 6-mm average expansion with retention in the short-term ( B 1 year) yielded a 4.71-mm residual expansion. Subsequently, this expansion during the short-term post-retention period was reduced to 3.88 mm. Finally, in the long-term post-retention study period only 2.4 mm of the residual expansion was reported to have remained. This 2.4 mm of expansion remaining after more than a year or more of post-retention period was no greater than what has been documented as normal growth. There is insufcient data to conclude that any useful expansion beyond that can be expected though normal growth was retained. Key words: maxillary expansion; meta analysis; relapse; retention
Dates: Accepted 28 December 2000 To cite this article: Clin. Orthod. Res. 4, 2001; 86 96 Schiffman P, Tuncay OC: Maxillary expansion: a meta analysis Copyright Munksgaard 2001 ISSN 1397-5927
Schiffman and Tuncay. Maxillary expansion meta analysis
Introduction
Perhaps to keep pace with an expanding economy if not the frontiers of science, for over a century malocclusions have been corrected with maxillary expansion as part of the treatment plan in patients of all ages. Numerous reports exist of dental and skeletal response of varying proportions, including reports from complete stability (1) to reports of considerable relapse (2) of the expanded maxillary arch. This is either because the concept has been around and in use for so long or has been used indiscriminately. Since its introduction, the indication and stability of maxillary expansion is continually debated in the literature. In an effort to understand the appropriateness and stability of maxillary expansion, we conducted a meta analysis of the available literature. As such, this report summarizes and evaluates the existing reports of stability and utility of maxillary expansion.
surgically assisted expansion and case report. These articles were eliminated from the original sample. The abstracts, when available, were reviewed and studies not within the scope of our study were eliminated. When abstracts were not available, the article itself was placed on a list for retrieval. The remaining 36 articles were located and the reference list of each article was hand-searched for additional clinical studies. The publication bias inherent in this manner of search is considered in the discussion section below. Of these 36 articles retrieved, only 11 of them met the initial exclusion/inclusion criteria.
Study selection criteria

Meta analysis is a statistical research design that has been increasingly used over the past 20 years to aggregate data, and to quantify and qualify dissimilar results (3). As originally dened by Glass (4) meta analysis is a statistical analysis of a large collection of results from individual studies for the purpose of integrating ndings. The meta analysis protocol for this investigation was designed to resolve the conicting reports that exist concerning the stability of maxillary expansion. Specically, we examined the individual study methods to determine to what extent, if any, maxillary expansion is a stable or indeed useful orthodontic therapy. In this analysis, any positive or negative deviation from the expanded position indicated instability. The term instability is objective, indicating a quantitative amount that has changed over time. A computerized Medline search was conducted for the years 1979 1999 to begin to locate all studies that examined the stability of transverse expansion of the human maxilla. The terms were entered individually as search terms. All subheadings were exploded and then limited to English language and human subjects. This initial sample of over 5000 articles was reduced by combining the original search terms with the terms cleft palate, protraction headgear, surgical expansion,
Inclusion and exclusion criteria are listed in Table 1. Inclusion criteria consisted of publication of a clinical trial in the English language between 1979 and the end of 1999. The studies had to address the transverse expansion of the maxilla and be conducted on human subjects. The outcome measures had to document one expanded measurement and one post-expanded measurement of maxillary intermolar width. The minimum sample size at the second measurement had to be equal to or greater than 10. Studies were excluded if patients were exclusively of the primary dentition, had a documented birth defect, which included a facial cleft or a craniofacial syndrome. Exclusion criteria also included surgical and surgically assisted expansion. Face mask therapy or maxillary protraction therapy, extraction treatment and functional appliance therapy were thought to introduce confounding factors and, therefore, studies that
Table 1. Initial exclusion/inclusion criteria
Exclusion criteria Inclusion criteria
Cleft lip/palate diagnosis Craniofacial syndrome diagnosis Surgically-assisted expansion Protraction headgear/facemask therapy Case reports Only primary dentition Functional appliance therapy Type of appliances unclear
English language Human subject Sample size]10 Expanded data and one post-e recording Retainer wear clear
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Table 2. Final studies

Study IDc Study reference
that displayed areas of contradiction serious enough to render the validity of the data questionable.
Procedure
165 191 156 195 199 181
Asanza et al. (5) Boysen et al. (6) Lindner-Aronson and Lindgren (7) Sandikcioglu and Hazar, 1997 (8) Moussa et al. (9) Spillane and McNamara (10)
documented these therapies were excluded. Reports of nonextraction treatment with xed appliances following the expansion phase were included. Clinical trials of maxillary expansion that addressed vertical and sagittal stability but not transverse stability were excluded. Use of a retainer did not exclude a study, but unclear documentation of the use of retainers did. The investigators reserved the right to disqualify any study
Two investigators participated in the study. They were blinded with respect to authorship, age of the article, journal of publication and funding source. All identifying print, as well as text offering personal commentary was blocked out. For the duration of this study, all trials evaluated were identied only by number. The identifying number for each study is listed with the reference in Table 2. Each investigator was given one copy of every blinded study and each initial evaluation was done independently. The evaluation consisted of coding and scoring each study with respect to pre-established characteristics. A cumulative meta evaluation score was calculated for each study. These characteristics are summarized in Table 3. Inter-examiner conicts
Table 3. Coding categories and meta evaluation factors

Category Divisions and meta analysis factors
Study design
Retrospective 1
Prolective 1.5 Alternate Tx 0 Random 2 3150 1.5
Prospective 2 Untreated 2
Control group
Historic or None 0
Treatment assignment
Non-random 1
Sample size
1030 1
\50 2
Methodologic soundness Ages provided Dental age Angle classication and malocclusion severity Appliance described Stopping rule used Statistics provided Expansion classication Rate and rhythm Over-expansion documented Standard deviations Time of activation, retention and/or post-retention recorded Bias and error considered
(+ or ) 0, 0.5, 1
(+ or ) 0, 0.5, 1
were resolved by consensus review. The evaluation of individual studies was done objectively to minimize introduction of bias. The evaluative components that were considered adhered to the basic principles of research and principles of orthodontic tooth movement. These components were determined prior to reading the paper. Each study was evaluated by specic coding that indicated characteristics of study design, population sample, documentation of data and methodological soundness of the research. In turn, these characteristics were used to determine an overall value for each study. The resultant numerical value was termed the meta analysis score and was used to develop a weighting scheme that reected the stability of maxillary expansion as a function of study design. An overall effect size was computed and aspects of study design were analyzed.
Table 4. Meta analysis factor for each study

Study IDc Meta analysis factor Study
165 191 156 195 199 181
6 4.5 4 6 2 5
Asanza et al. (5) Boysen et al. (6) Lindner-Aronson and Lindgren (7) Sandikcioglu and Hazar (8) Moussa et al. (9) Spillane and McNamara (10)
Results
Six studies remained in the nal analysis. The mean age (of studies reporting individual or mean ages) at time of expansion was 10.8 years. The mean expansion after adjustment according to the principles of meta analysis principles was 6.00 mm with a standard deviation (SD) of 1.29 mm. Of the 6 mm average, 4.89 mm was retained while the retainers were worn. Five studies provided retention data (165, 191, 156, 195, 181), four studies provided post-retention data (191, 156, 181, 199) and three studies provided both retention and post-retention data (191, 156, 181). The studies with their corresponding meta analysis factor are given in Table 4 and the meta analysis data are summarized in Table 5. The wearing of retainers resulted in an overall loss of 18.5% of the original gain. Short-term results (less than 1 year) displayed a mean of 4.71 mm, or retention of 78.5% of the original expansion. Longer-term retention studies showed a mean retention of 5.47 mm or 92%. Table 6 displays study design characteristics for studies using retainers. The lack of uniformity among the studies along with improper study design and reporting did not permit a statistical meta analysis. The data are, therefore, presented in a tabular format in Table 7 and discussed. For a more detailed description see
www.clinorthodres.com/cor-o-124 appendices for the raw data displayed on the web site. The mean expansion of 6 mm was reduced to 3.88 mm when studies reporting post-retention data were analyzed. Post-retention data show a total loss of 35.5% of the original transverse increase. Studies reporting short-term post-expansion data maintained 75% while longer-term post-expansion data (\ 50 months) demonstrated a mean loss of 40% of the expansion. Data from post-retention studies are given in Table 8. Further examination of the data for Hyrax, removable and quad helix therapies are in Table 9 and show Hyrax expansion therapy relapses 50%. The quad helix and removable appliances retained 64%. The data, as reported for each study, are summarized in Table 10.
Discussion
Meta analysis is used to quantify research data. Its ultimate utility in orthodontics lies in the incorporation of results into clinical decision making. As a research method that weighs and combines evidence, meta analysis produces evidence that is more powerful than the original studies. Original studies using weak designs overestimate treatment effects, while studies using stronger designs tend to underestimate treatment results (11). A properly executed meta analysis controls for this imbalance. Meta analysis is subject to the same bias and error as other methods of scientic research (12). Limiting study inclusion invites bias. Publication bias is generally thought to result in greater effect size as studies that report greater results (expansion or residual expansion) are more likely to be published. Citation bias
89
occurs when individual articles are referenced. Studies that report large effect size are more likely to be referenced regardless of study quality. Similarly, the use of reference lists to locate studies to conduct a meta analysis contributes to overall bias. Also, English language bias results because investigators from nonEnglish speaking countries are more likely to report their positive ndings in an English language journal. Journals published in developing countries are less likely to be indexed in Medline. In orthodontics, meta analyses are difcult to conduct because of the nature of the available literature (13). The potential problem of biases identied above can be examined in a funnel plot analysis (Fig. 1).
Table 5. Stability data
Study IDc MA factor Expansion obtained
Asymmetry indicates either bias or heterogeneity. Eliminating Study 156, for example, signicantly reduces the asymmetry apparent in the funnel plot analysis. A Students t-test of the means for the sample including 156 and the sample excluding 156 was done. The difference in the means could be attributed to chance alone when p= 0.10, but not when p=0.05. The asymmetry resulted from lack of homogeneity when Study 156 was included. Because Study 156 was qualied based on inclusion/exclusion criteria, a signicance level of p= 0.10 was accepted and the data from Study 156 was included in the overall analysis. Although maxillary expansion has been a component of orthodontic treatment for over 100 years, in
Expansion remaining
Expansion obtained (weighted)
Expansion remaining (weighted)
Overall stability
165 191 156 195 199 181 Total 6 4.5 4 6 2 5 27.5 5.98 5.13 7.9 5.1 6.9 5.9 6.15 4.12 4.99 5.95 4.7 5.5 4.82 4.38 35.88 23.1 31.6 30.6 13.8 29.5 164.48 24.72 22.46 23.8 28.2 11.0 25.5 118.37
Stability with retainer wear

165 191 156 195 181 Total Average % Retained 6 4.5 4 6 5 25.5 6.0 5.98 5.13 7.9 5.1 5.9 6.0 4.12 4.99 5.95 4.7 5.1 4.97 5.9 35.88 23.1 31.6 30.6 29.5 150.68 4.89 83 24.72 22.46 23.8 28.2 25.5 124.68
Stability post -retention

191 156 181 199 Total % Retained 4.5 4 5 2 15.4 5.13 7.9 5.9 6.9 6.45 3.58 3.56 4.82 5.5 4.37 23.1 31.6 29.5 13.8 98 16.11 14.24 24.1 11.0 65.45 66
Table 6. Selected characteristics of retention studies

ID Design Days1 Appliance R/R2 Speed2 MC4 Over expanded Retention protocol
Short -term data (less than 1 year)

165 Pp5 191 Pp 195 Pp 90 90 135 Hyrax, bonded Quad helix, removable Hyrax, quad Removable 2t/d 2t/w 2t/d 1t/eod Rapid Slow Rapid Slow Posterior X-bite Uni post X-bite w functional shift Unilateral X-bite Bilateral X-bite Yes 1/2 cusp No Yes Passive appliances 90 d passive appliances
Long -term data (more than 1 year)

156 R6 181 Pl
7
602 135
Hyrax Hyrax, quad removable
? 2t/d 1t/eod
3
Rapid Rapid Slow

4
Bilateral posterior X-bite Unilateral X-bite Bilateral X-bite

5
No Yes
Yes. Type not given Passive appliances
Days= days in retention.
Rate/rhythm.
Speed=classication.
MC= Malocclusion.
Pp= prospective study.
R = retrospective study.
Pl= prolective study.
the past 20 years only six reported studies meet liberal inclusion/exclusion criteria. Unfortunately, these six studies are characterized by confusing denitions and variables. Rapid expansion was undened by Study 156, dened as twice as rapid for Study 181 as 191, and twice as rapid with pre-loading and additional inofce activation for Study 199. Slow expansion ranged from two activations per week (Study 191) to 3.5 activations per week (Study 195). Over-expansion was a goal of two-thirds of the studies (181-195-199-165). Time in retention appliances ranged from 90 days (191, 165) to 5 years (156). Stopping rules, when reported, varied greatly with extremes of proper transverse occlusion (191), and mandibular arch completely contained by the maxillary arch (199). The difference in expansion between these two extremes is approximately 10 mm. The initial malocclusion, when documented, varied from unilateral posterior crossbite with functional shift (191) to bilateral crossbite (156). Sample size ranged from 14 (165) to more than 80 (181). The mean age at the time of treatment ranged from 8.5 years (191) to 14.4 years (156) while the actual ages ranged from 6.4 (191) to 21.5 (156). Certainly because of, not despite, such range of variation in the study design of published articles the question still remains: is maxillary expansion stable? As we dened stability as any deviation from the expanded position, we must conclude that it is not. Even if we choose a more liberal parameter and dene stability as any increase over that would be expected
through normal growth and development (14), we must still conclude that it is not. Notwithstanding the argument that expansion of a skeletally constricted maxilla enables the maxilla to catch-up with its normal growth potential, our data clearly show that a weighted expansion of 6 mm can be expected to decrease by 40% within 5 years. The original 6 mm will be between 3 and 4 mm by this time. An increase of 3 mm can be expected due to growth between the ages of 10 and 18 (14). Of the 34 mm residual expansion, no more than 1 mm can be attributed to anything other than growth. This may include the maxillary expansion, but must also include orthodontic tooth movement (desirable or undesirable) as well as measurement error, and in the case of radiographic data magnication error and changes in head position must be considered. Proponents of maxillary expansion hold that it eliminates extractions. This is a rather weak argument as it is inconceivable that there can be too many conditions where all the teeth cannot be aligned with or without expansion. But is that the right treatment? The non-extractionists would argue parents are more likely to accept a treatment plan that does not involve the cruelty of yanking teeth out. Does that mean they are happy to know instead of extractions, their childrens jaws and facial bones will be brutally torn apart, sutures ripped and bones cracked? Clearly, the justication is not only humorous, but also rather weak. Even if we could legitimately attribute the 1 mm increase in maxillary width to the expansion achieved
91
Table 7. Characteristics of the six papers used in the meta analysis

195 MA=6 181 MA=5 199 MA=2
Research design Control group Tx assignment Sample size Subgroup sizes Pre-Tx equivalent Age (mean) Age (range) Dental age Angle class Malocclusion Appliance Removable Stopping rule Expansion class Rate and rhythm
Prospective Alternate Tx Random 30 10, 10, 10 Yes H=6.6y, Q=8.9y, R=8.7y
+2 +0 +2 +1 +0.5
Prolective Unclear Bias \80
+1.5 +0 +1 +2 +0.5
Retrospective No Bias 55
+1 +0 +1 +2 1
Mixed Not stated UXB, BXB Hyrax, quad, removable
Early-mixed
U+BXB Bonded acrylic splint Active plates
No H=Rapid, O=Slow, R=Semi H=2t/d, R=1t/eod
Not provided Rapid 1t/d
Md. contained by maxilla Rapid Preloaded, then 1/4t AM+PM, plus additional inofce
Over-expanded? Mm (EOA) Standard deviation Days of activation Mm EOR Standard deviation Days of retention Mm post-retention Standard deviation Days post-retention Retention protocol
Yes H=5.5, Q=5.6 R=4.1 H=3.0, Q=2.7, R=2.2 H=19.2, Q=56, R=165 H=5.4, Q=5.1, R=3.6 H=2.3, Q=3.1, R=2.1 H=90, Q=105, R=210
Yes 5.9 1.6 165 5.1
Yes 6.9 4.1
365 4.82
\730 5.5 4.0
No data H, Q+R:Passive appl
270 PassAppl 45 m Then rem 1y
5.620.4 years Mx-rem 2y Md-bonded +0 Yes 1
Error addressed
Yes
+0.5
Yes
165 MA=6
191 MA=4.5
156 MA=4
Research design Control group Tx assignment Sample size Subgroup sizes Pre-Tx equivalent Age (mean) Age (range) Dental age Angle class Malocclusion
Prospective Alternate Tx Random 14 7, 7 Yes
+2 +0 +1 +1 +1
Prospective Alternate Tx Unclear 34 17, 17 Yes 8.5
+2 +0 +1 +1.5 +1
Retrospective No Bias 22
+1 +0 +1 +1 +0.5
14.4 10.621.5
8.516 Mixed Not stated Posterior XB
6.411.3 Mixed Not stated UPXB w/fx shift
CII BXB
Table 7. (Continued)
195 MA=6 181 MA=5 19 MA=2
Appliance Stopping rule Expansion class Rate and rhythm
Hyrax, bonded, ????? 1/2 Cusp over expanded Rapid H=2t/d B=2t/d
Quad helix, removable Proper occlusion Slow Q=none R=2 t/w No Q=5.61 R=4.65 Q=1.78 R=1.52
Hyrax No Rapid
Over-expanded? Mm (EOA)
Yes H=6.01 B=5.94
7.9 mm (3.116)
Standard deviation
Days of activation
Q=101.2 R=115.4
60
Mm EOR
H=4.4 R=3.84
Q=5.59 R=4.38 Q=0.86 R=0.71
5.95
Standard deviation
3.58
Days of retention
H=90 R=90
Q=90 R=90 Q=4.09 R=3.07
602
Mm post-retention
3.56
Standard deviation
Q=1.08 R=1.28
2.76
Days post-retention
Q=90 R=90
1715
Retention protocol Error addressed
H+R:Passive Appl 90 days Yes +1
Clearly dened Yes 1
Claimed not described No +0.5
Table 8. Selected characteristics of post-retention studies

ID Design Days1 Appliance R/R2 Speed3 MC4 Over expanded Protocol
Short -term data (less than 1 year)

181 Pl5 191 Pp6 270 Bonded acrylic splint 1t/d Rapid Unilateral X-bite bilateral X-bite Yes Passive appliances 44 m, then removable 90 Quad helix removable 2t/w Slow Unilat post X-bite w functional shift No
Long -term data (more than 5 years)

199 R7 \1825 Active plates removable Preload, 2t/d plus Rapid additional 156 R
1
Maxillary contains Md
1715
2
Hyrax
R/R= Rate/rhythm.
3
?
Speed =classication.
4
Rapid
Bilateral X-bite
5
No
6
Days in retention.
MC= Malocclusion.
Pl= prolective.
Pp= prospective.
R = retrospective.
93
Table 9. Expansion data

Study IDc Sample size MA factor Expansion obtained WTD1 Expansion retained Expansion post-retention
Value
Value
WTD
Value
WTD
Quad helix expansion data

191 195 Totals % Retained 17 10 27 4.5 6 10.5 5.61 5.6 25.25 33.5 77.15 95 5.59 5.1 25.16 30.6 55.76 64 4.09 N/A 18.41 N/A 18.41
Hyrax expansion data

165 156 195 % Retained 7 22 10 6 4 6 6.01 7.9 5.5 36.1 31.6 33.0 4.4 5.95 5.4 26.4 23.8 32.4A 82 N/A 3.56 N/A N/A 14.24 N/A 49
Removable expansion data

191 195 % Retained
1
17 10
4.5 6
4.65 4.1
20.93 24.6
4.38 3.6 91
19.71 21.6
3.07 N/A 68
13.82 N/A
WTD= weighted.
Table 10. Studies therapeutic regimen and residual expansion data (as reported)
Study IDc Days of activation Months in retention % Expansion retained Months in post-retention % Expansion retained
165 191 181 156 199 195
N/A 108 165 60 N/A 80
3 3 12 19.2 \24 4.4
69 97.3 86.4 75.3 79.7 93.2
N/A 3 8.9 56.2 \67 N/A
N/A 69.8 81.7 45.1 79.7 N/A
years before, we are still left with the following difcult questions: 1. Is maxillary expansion worth the 1-mm increase? Is it worth the risk of treatment, the time of treatment or the cost of healthcare dollars? 2. Is maxillary expansion the appropriate treatment? If the initial malocclusion represents craniofacial or nasomaxillary equilibrium, is it appropriate to treat a maxillomandibular discrepancy by widening the maxilla and upsetting the equilibrium? Should we
consider simpler options such as correction with archwires, or alternative options like narrowing the mandibular arch? 3. Do we have sufcient scientic data to answer these clinical questions? Results of this study lead us to conclude: 1. Stability of maxillary expansion is minimal. 2. Early correction of a developing crossbite may or
Structured Abstract
Authors Schiffman, P., Tuncay, O. Objectives To analyze, evaluate, quantify and summarize the existing reports on the stability of maxillary expansion and to use the results of this analysis to explain the existing discrepancies in the literature. Design A meta analysis. Setting and Sample Population Articles retrieved by a computerized Medline search were subjected to pre-established exclusion and inclusion criteria. Experimental Variable Maxillary expansion trials that fullled the exclusion/inclusion criteria were scored according to the principles of meta analysis. Changes and stability in the maxillary intermolar width were considered to evaluate expansion. Outcome Measure An immediate post-expansion measurement and at least one post-expansion measurement were manipulated to reect a weighted average for expansion and relapse. Post treatment data were compared to expected growth changes. Results The mean expansion after adjustment according to the principles of meta analysis was 6.00 mm with a standard deviation of 1.29 mm. Of the 6-mm average, 4.89 mm was retained when wearing retainers and 3.88 mm remained postretention. Conclusion Results of this analysis lead us to conclude that maxillary expansion stability is minimal, that correction of a developing crossbite may or may not be benecial and that there is no adequate available literature to study the effect of maxillary expansion because reasons for expansion (either to correct a skeletal or dental crossbite or for anteroposterior correction) are not stated.
Fig. 1. Studies 195-181-199-191-165 form an upside-down funnel shape. The symmetry seen indicates non-bias and homogeneity. If the outlier study 156 were to be excluded, then the funnel plot becomes even more symmetrical. Study 156 was included in the meta analysis.
may not be benecial. Unfortunately, the available literature is inadequate to study the effect of expansion of skeletal constriction in the maxilla. Published studies do not disclose the indication for expansion, whether expansion was done for crossbite correction or for anteroposterior correction. 3. Although a recommendation for a prospective clinical trial only for patients exhibiting crossbite seems appropriate, ethically one cannot study the effect of maxillary expansion in subjects where no transverse problems exist. The analysis of reports in the literature lends no support to develop a hypothesis for such a randomized trial. It can be stated, therefore, there is insufcient evidence to conclude that any expansion beyond that is expected through normal growth is retained.
95
References
1. Haas AJ. Palatal expansion: just the beginning of dentofacial orthopedics. Am J Orthod 1970;57:21955. 2. Timms DJ. An occlusal analysis of lateral maxillary expansion with midpalatal suture opening. Trans Eur Orthod Soc 1968;44:73 9. 3. Chalmers I. The Cochrane collaboration: preparing, maintaining, and disseminating systematic reviews of the effects of health care. Ann NY Acad Sci 1993;703:15663. 4. Glass GV. Primary, secondary and meta-analysis of research. Edu Res 1976;5:308. 5. Asanza S, Cisneros GJ, Nieberg LG. Comparison of hyrax and bonded expansion appliances. Angle Orthod 1997;67:15 22. 6. Boysen B, La Cour K, Athanasiou AE, Gjessing PE. Three-dimensional evaluation of dentoskeletal changes after posterior cross-bite correction by quad-helix or removable appliances. Br J Orthod 1992;19:97107.
7. Lindner-Aronson A, Lindgren J. The skeletal and dental effects of rapid maxillary expansion. Br J Orthod 1979;6:259. 8. Sandikcioglu M, Hazar S. Skeletal and dental changes after maxillary expansion in the mixed dentition. Am J Orthod Dentofac Orthop 1997;111:321 7. 9. Moussa R, OReilly MT, Close JM. Long-term stability of rapid palatal expander treatment and edgewise therapy. Am J Orthod Dentofac Orthop 1995;108:478 88. 10. Spillane LM, McNamara JA. Maxillary adaptation to expansion in the mixed dentition. Sem Orthod 1995;3:176 87. 11. Antczak-Bouckoms A. The anatomy of clinical research. Clin Orthod Res 1998;75:75 9. 12. Egger M, Davey Smith G. Meta-analysis: bias in location and selection of studies. Brit Med J 1998;316:61 6. 13. Tulloch JFC, Antzack AA, Tuncay OC. Review of clinical research in orthodontics. Am J Orthod Dentofac Orthop 1989;95:499 504. 14. Bjork A, Skieller V. Growth of the maxilla in three dimensions as revealed radiographically by the implant method. Br J Orthod 1977;4:53 6.
962Clin Orthod Res 4, 2001/8696
CLINICAL REPORT
HJ Donker B Melsen EVG Frandsen
Bacterial degradation of composite bonding materials
Authors affiliations: H.J. Donker, B. Melsen, Department of Orthodontics, Royal Dental College, University of Aarhus, Aarhus, Denmark E.V.G. Frandsen, Department of Oral Biology, Royal Dental College, University of Aarhus, Aarhus, Denmark Correspondence to: E.V.G. Frandsen Department of Oral Biology The Bartholin Building University of Aarhus DK-8000 Aarhus C Denmark Tel: + 45 8942 1739 Fax: +45 8619 6128 E-mail: EF@microbiology.au.dk
Abstract: The causes of bracket loss during the late phases of orthodontic treatment have hitherto been considered to be of mechanical nature (e.g. trauma, high forces applied). Recently, it was hypothesized that bacterial degradation of composite resin could be a reason for late bracket failure. This was based on the observation of apparently degraded composite on bracket bases sent to a recycling company, and on a weight loss of 0.1 1% of a limited number of composite resin foils incubated with bacteria. To further elucidate the basis for this hypothesis, we examined brackets, immediately after debonding, for signs of potential decay and tested the ability of selected bacterial species to degrade composites. Out of a total of 1056 brackets collected, 6.2% displayed signs of decay indicative of inclusion of air bubbles, corrosion of the bracket base and discoloration of the composite and comparable to the decay observed on brackets received from the recycling company. Composite discs of two different brands were each incubated with either of ve strains representing different bacterial species. The incubation lasted 3 months or until the bacteria had died. There was no signicant difference in weight change of the discs incubated with bacteria and control discs incubated without bacteria. Thus, our results do not support that bacterial degradation of composite resin bonding materials is a likely cause of bracket loss. Key words: bacteria; bonding; bracket
Dates: Accepted 15 January 2001 To cite this article: Clin. Orthod. Res. 4, 2001; 112 118 Donker HJ, Melsen B, Frandsen EVG: Bacterial degradation of composite bonding materials Copyright Munksgaard 2001 ISSN 1397-5927
Introduction
Lost brackets in the course of orthodontic therapy is detrimental to treatment and causes inconvenience and added expense to both the patient and the or-
Donker et al. Bacterial degradation of composites
thodontist. Reportedly, 813% of brackets are lost during treatment (1, 2). Bracket loss typically occurs either shortly after bonding or late, after prolonged presence in the oral cavity (3). Apart from bracket design and bonding material related causes, early bracket loss is presumably a result of insufcient adherence because of contamination with saliva, insufcient etching time, incomplete polymerization of the bonding material, inadequate adaptation of the bracket to the tooth surface (uneven or thick adhesive layer), or premature engagement of the wire. Major reasons for bracket loss at a late stage may be mechanical injury caused by chewing hard or sticky food, high forces applied in the intermediate to late treatment stage (torque), or trauma to the teeth (4). Based on the observation of apparently degraded composite on bracket bases sent to a recycling company, the hypothesis was raised that bacterial degradation of dental composites may be a reason for late bracket failure in orthodontic treatment (5). In support of this hypothesis Matasa (5) found that bacteria incubated with composite resin foils in carbon-decient, articial saliva survived longer compared with controls without foils and that the foils lost 0.1 1% weight following incubation with bacteria. Microbial degradation of different types of polymer carbon materials is a well-known phenomenon. Many natural polymers are inherently biodegradable, but biodegradability of chemically modied polymers varies, depending on the extent of the modication. Little is known about the possibility of degradation of composite resins used in the oral cavity. Theoretically, it may be expected that acid end-products from bacterial fermentation and esterase produced by bacteria may degrade composite resin. This is partly substantiated by experimental ndings. Freund and Munksgaard (6) have found that the acrylate components of dental composites are softened in vitro by chemicals such as ethanol, certain acids, and porcine liver esterase, resulting in reduced surface hardness and enhanced wear of the composite resins. Similar results on the effect of porcine liver esterase have been reported by de Gee and coworkers (7) whereas acids in their experimental setup did not affect the wear rate. Larsen and coworkers (8, 9) have, furthermore, observed that enzymes in human saliva are capable of hydrolysis of dimethacrylates.
Although dental composites may be susceptible to breakdown by acids and esterase it is not known to which extent this may be induced by bacteria. In order to further elucidate the basis for the proposed hypothesis of bacterial degradation of composites as a cause of bracket failure, the aims of the present study were to examine debonded brackets for signs of potential decay and to test the ability of strains of selected bacterial species to degrade composites.

Collection and examination of debonded brackets
For a period of 6 months a total of 1056 brackets from 62 individuals (median 17, range 228 per individual) were collected in the postgraduate clinic at the Department of Orthodontics at the Royal Dental College of Aarhus when orthodontic appliances were removed. The brackets were stored in air at room temperature until examination under a dissecting microscope (magnication 840) could be performed. A tentative classication of alterations indicative of potential decay was performed and representative brackets were photographed. For comparison, brackets were bonded to a total of 20 extracted caries-free human canines (kindly donated by A. Richards, Royal Dental College of Aarhus) with either Rely-a-bond (Reliance Orthodontic Products Inc., Itasca, Illnois; 10 teeth) or System 1+ (ORMCO; 10 teeth). These were the two bonding materials in use at the Royal Dental College of Aarhus, during the study period. The brackets were debonded after 24 h. In addition, 71 debonded brackets with presumed bacterially induced decay were received from C. G. Matasa (Ortho-Cycle Co., Hollywood, FL, USA).
Preparation of discs
A large portion of each of two composites, Concise (3M Unitek, a two-component chemical curing material) and Enlight (ORMCO, a one-component light curing material) was prepared and pressed between two glass plates into a thickness of approximately 1 mm. The plates were cut into squares of approximately 2.5 mm2, using a diamond cutter mounted in a high-speed handpiece. Only discs without surface defects, as observed under a dissecting microscope, were
113
used in the experiments. The discs were numbered, cleaned in an ultrasonic bath, left for drying on lter paper until no moisture was visible, weighted, and sterilized using gamma irradiation. All weight measurements were carried out on the same analytical weight (Mettler, Zurich) and by the same person.
Bacterial strains and culture conditions
periments were repeated twice. The weight changes of test and control discs were compared using the method of univariate analysis of variance. The specic combination of one bacterial species with one type of disc, one type of liquid, and renewal or not of liquid was not tested because the statistical power of this analysis would have been very weak when based on double observations only.
Representative strains of the following species were used: Pseudomonas aeruginosa (AAB15, donated by Jeanet Lomholt, University of Aarhus, Denmark), Streptococcus mutans (strain Ingbritt) and Streptococcus sanguis (SK1= ATCC 10556T, (American Type Culture Collection), both donated by M. Kilian, University of Aarhus, Denmark), Fusobacterium nucleatum (CCUG 9126, Culture Collection of the University of Goteborg, Sweden) and Prevotella melaninogenica (CCUG 4944B=ATCC 25845T). The bacterial strains were grown on plaque agar and in liquid plaque broth (10) in an anaerobic chamber at 37C except for P. aeruginosa which was grown at 37C in air+10% CO2.
Experimental setup
Results
Among a total of 1056 collected debonded brackets from the orthodontic department in Aarhus, 65 (6.2%) had signs of decay on the composite left on the bracket base. Following comparison with the experimentally debonded brackets, purely white, opaque discoloration of the composite material was considered to be induced by the debonding action. Brackets exhibiting only such changes were not included into any of the potential decay groups. Twenty-three of the brackets had a dark, sometimes greenish discoloration of the composite and the bracket base itself had a corroded appearance (Fig. 1A). Pockets and channels (worm-like) in the composite starting at the outer edges of the bonding material and extending towards the center were found on another 23 brackets. Some of these also presented a mushy core, more yellowish in colour than the composite itself (Fig. 1B). Finally, an orange to brown discoloration of the bonding material, which could be localized as well as generalized, was observed on 19 brackets (Fig. 1C). The brackets showing signs of potential breakdown were assigned to only one category each, although some brackets presented with more than one type of decay (Fig. 1C,D). Of the 71 brackets received from Matasa, 33 were categorized as pockets and channels, and nine presented with a widespread, uniform, pale-yellow opaque discoloration not found in our material but resembling the appearance of our freshly debonded brackets. The remaining 29 of Matasas brackets had no decay. The variation of repeated weight measurements of eight discs on the same day was 0.06% whereas, the variation of three consecutive weight measurements of 20 discs over a 5-week period was 0.11%. Consequently, the weight measurements are presented in
A sterile Concise disc was added to each of six screw cap test tubes containing 15 ml of sterile plaque broth. Subsequently, 0.5ml of liquid grown bacteria of the ve species tested was added to ve of the test tubes while the last tube served as a control. Tubes containing P. aeruginosa were incubated in air+ 10% CO2 and the rest of the tubes were incubated anaerobically. The same procedure was performed with Enlight discs. One such series of test tubes was subjected to renewal of half of the broth twice a week and checked for viability and contamination by inoculating a drop from the contents of the test tube onto a plaque agar plate once every week. Another series of test tubes were left without renewal of liquid and checked for viability and contamination once every 2 weeks. The experiments were run for 90 days or until the bacteria had ceased growing on the control plates. The composite discs were rinsed with distilled water and cleaned by slight ultrasonic treatment. After drying in room temperature on lter paper, until no moisture was visible, the discs were weighed. The same experimental setup was used for incubation of discs with bacteria in articial carbon-decient saliva (5). All ex114 2Clin Orthod Res 4, 2001/112118
Fig. 1. Brackets with the types of decay observed among 1056 collected debonded brackets. (A) Dark to green discoloration and corroded appearance of bracket base; (B) pockets and channels; (C) orange to brown discoloration; (D) bracket with multiple types of decay; corroded appearance of bracket base in conjunction with pockets and channels and orange discoloration. The gures on the photos indicate the number and proportion of brackets with each type of decay.
milligrams with one decimal point. The experimental setup to test bacterial degradation of the composites might, theoretically, lead to a weight change in two opposite directions: a weight gain as a result of water absorption and a weight loss as a result of bacterial degradation. Pre-immersion of both Concise and Enlight discs in water resulted in a steady weight increase (mean 0.78%, range 0.71 1.08% for eight discs) over a 3-week test period. It was thus not possible to correct for water absorption by pre-immersion in water for a xed, limited time period before starting the experiment. Instead, the weight change of the test discs incubated with bacteria was measured relative to the weight change of the control discs which were included in all experiments. The basic setup of the experiments to test bacterial degradation of composite discs included six test tubes each with a Concise disc (a chemical curing material) and six test tubes each with an Enlight disc (a light curing material). These were inoculated with bacteria of either of the following ve species, P. aeruginasa, S. mutans, S. sanguis, F. nucleatum, and P. melaninogenica while the last tube without bacteria served as
control. All experiments were repeated leading to a total of 24 tubes in each experiment. In the rst experiment the discs were incubated with bacteria immersed in broth that was renewed twice weekly to ensure prolonged survival and growth of the bacteria. The experiment lasted 3 months or until the bacteria had died. Presence of another carbon source (broth) than the composite discs was chosen deliberately, because this would mimic the situation in the oral cavity where there is also a constant supply of carbon from dietary sources and salivary glycoproteins. This procedure ensured survival of the bacteria for at least 2 months except for the combination of P. melaninogenica with the Concise disc where the bacteria survived for 3 months the rst time, but only for 5 weeks when the experiment was repeated. In the second experiment the broth was not renewed which reduced survival time for P. melaninogenica to 2 weeks (mean value) and for S. sangius to 2.5 weeks. In the third experiment carbon-decient articial saliva was used with the intention of forcing the bacteria to use the composite as a carbon source. This experiment was also performed with renewal of half of the articial saliva twice weekly, in order to ensure prolonged survival of the bacteria through removal of toxic waste products. The fourth experiment had a setup identical to the third experiment except that the articial saliva was not renewed. There was no difference in survival time between the third and the fourth experiment. Pseudomonas aeruginosa survived for the entire experimental period but for the rest of the test species the survival time was short (mean value 3 weeks). To illustrate the data, Table 1 presents the weight measurements of the rst series of experiments using Enlight discs, plaque broth as incubation liquid with renewal twice weekly. Fig. 2 presents the relative weight changes (weight change in relation to pre-experimental weight of the discs) observed in all experiments combined (80 discs incubated with bacteria and 16 control discs). Dividing the data into two groups according to type of composite used, to type of liquid used, or to whether the liquid was renewed or not, gave similar plots (data not shown). The statistical analysis was performed initially on all data pooled into two groups, the test group containing all data on the 80 discs incubated with bacteria and the control group containing all data on the 16 control discs. The null hypothesis was the same mean relative weight change
Clin Orthod Res 4, 2001/112 1182
115
Table 1. Change of weight of Enlight composite discs following incubation with bacteria in plaque broth of which half is renewed twice weekly
Species
P. aeruginosa
31.51 31.9 3 months +0.4 +1.3%
P. melaninogenius
F. nucleatum
S. mutans
S. sanguis
Control
Weight start Weight end Duration Weight change Weight change

1
46.6 46.9 3 months +0.3 +0.6%
44.7 44.9 2 months +0.20 +0.4%
48.2 48.0 3 months 0.2 0.4%
31.2 31.6 3 months +0.4 +1.3%
42.3 42.8 3 months +0.5 +1.2%
Weight unit is mg.
in the test group and in the control group. The relative weight change for the control group was a gain of 0.20% (SE 0.17%) with a 95% condence interval of between 0.14 and 0.54%. The weight change for the test group was a gain of 0.22% (SE 0.19%) with a 95% condence interval of between 0.36 and 0.39%. By subtracting the weight change of the control group from that of the test group, the resulting weight change attributable to presence of bacteria was a gain of 0.015%. The null hypothesis could not be rejected (p= 0.937) and thus the data did not support the concept that bacteria had induced a weight change of the composite discs. The analysis was repeated with the data divided into six groups, corresponding to the ve groups of bacte-
rial species and the control group. The null hypothesis was the same mean relative weight change in all groups (no effect of individual species). The results of this analysis are presented in Table 2. The estimated relative weight change in all groups was a weight gain. Accordingly, the null hypothesis could not be rejected (p = 0.932); the data did not support a concept of a weight change induced by any of the bacterial species. The same conclusion was reached even when the data were corrected for disc type, liquid type, or renewal or not of liquid (results not shown).
Discussion
The present study was undertaken to test the basis for the hypothesis that bacterial degradation of composite resin is a likely reason for bracket failure during orthodontic treatment. The hypothesis was raised by Matasa (5) and based on his examination of composite residue left on brackets received for recycling. Sixty-ve brackets (6.2%) out of a total of 1056 brackets collected at the orthodontic clinic in Aarhus were affected with potential decay and had either one or a combination of the three types of decay described. The most predominant decay type in our material was the worm-like decay (Fig. 1B) because it also constituted part of the orange-brown discoloration type (Fig. 1C). By visual inspection this looked rather similar to an area of air bubble inclusion with or without discoloration. Our black discoloration (Fig. 1A) could be suggestive of corrosion of the bracket material. Convincing evidence of bacterially induced decay was not observable by visual inspection of brackets as most of the alterations looked as if they could have been introduced by other causes. These
Fig. 2. The weight change of composite discs incubated with and without bacteria. All experiments are combined and each + represents one disc.
116 2Clin Orthod Res 4, 2001/112118
Table 2. Analysis of variance for control group and individual bacterial species groups
Group Mean effect of bacteria (% weight change) SE (%) 95% condence interval Estimated relative weight change (%)
Control (n=16)
0.17 0.11 0.10 0.10 0.05 0.08 0.24 0.24 0.24 0.24 0.24
0.14 to 0.55 0.37 to 0.60 0.58 to 0.39 0.39 to 0.58 0.44 to 0.53 0.57 to 0.40
0.20 0.31 0.10 0.30 0.25 0.12
P. aeruginosa (n=16) P. melaninogenica (n=16) F. nucleatum (n=16) S. mutans (n=16) S. sanguis (n=16)
brackets were still in situ at the time of collection because they were sampled at the time of debonding. So apparently, the potential decay seen on the bonding material was not enough to be the sole cause of bracket loss. The majority of the brackets with decay received from Matasa looked similar to our worm-like decay (Fig. 1B). Originally Matasa (5) used a slightly different description of the composite alterations, but there were major points of resemblance between his description and ours. However, the nine brackets we received resembling his high porosity category with widespread pale-yellow opaque discoloration was not observed among our collected brackets. Instead, these brackets had a high resemblance to the opaque discoloration of our experimentally debonded brackets except for the colour. Consequently, even the decay on the brackets received from Matasa looked as if it could have had other causes than bacterial. The representative strains of the various species tested for their ability to degrade Concise and/or Enlight discs were chosen to represent early facultative colonizers of the teeth (S. sanguis) and obligately anaerobic organisms (P. melaninogenica, F. nucleatum) because Matasa had described both an aerobic and an anaerobic type of decay. In addition, S. mutans was included, because this was the only species causing a considerable decay of the composites in Matasas experiments (5). Finally, P. aeruginosa was tested because it is a known esterase producer and, therefore, theoretically capable of chemically attacking the composite material (11). Moreover, it was cultivated from the brackets in Matasas experiments (5), and it would be a likely candidate of an organism causing decay during storage of the brackets in a
humid environment before sending them to the recycling company. The experimental setup ensured survival of only P. aeruginosa for the entire period in all experiments and S. mutans in some of the experiments but the prolonged survival of these species compared with the others did not lead to degradation of the composite discs not even when articial carbon-decient saliva was used with the intention of forcing the bacteria to degrade composite in order to get carbon for growth. From the plot of pooled data (Fig. 2) it looked as if there was no difference between the weight change of the composite discs incubated with bacteria and the control discs. The statistical analysis supported these observations; the null hypothesis (null effect of bacteria) could never be rejected. As mentioned in the results section we abstained from testing the specic combination of one particular species with one particular combination of type of disc, type of liquid, and renewal or not of liquid. This would be a very weak statistical analysis and would have required many samples of each in order to make a qualied test. So, we cannot rule out that a specic combination of the parameters might have resulted in a signicant loss of composite material. Likewise, it cannot by ruled out that a longer observation period would have revealed a difference. In Matasas experiments weight losses of 0.1 1% over a 60-day period were considered true loss induced by the bacteria (5). It was not possible to deduce from his article how many discs were tested, the results on the individual samples were not given, and there was no indication of repetition of experiments or use of statistical analyses. It is, therefore, not possible to verify whether he observed a true weight
117
loss, but his gures were within the limits of variation that we observed when looking at the weight changes of our control discs. Our results do not support the hypothesis that dental composites are degraded to any appreciable extent in vivo. The results of our incubation experiments indicate that the inuence of bacteria on degradation of composites is negligible, under the experimental circumstances used.
Acknowledgements: We thank C. G. Matasa for providing some of his original brackets for comparison. The technical assistance of L. Friis is gratefully acknowledged. M. Frydenberg and H. Hundborg are thanked for the assistance in analyzing the data.
References
1. Zachrisson BU. A posttreatment evaluation of direct bonding in orthodontics. Am J Orthod Dentofac Orthop 1977;71:17389. 2. Miguel JAM, Almeida MA, Chevitarese O. Clinical comparison between a glass ionomer cement and a composite for direct bonding of orthodontic brackets. Am J Orthod Dentofac Orthop 1995;107:484 7. 3. de Saeytijd C, Carels CEL, Lesaffre E. An evaluation of a lightcuring composite for bracket placement. Eur J Orthod 1994;16:541 5. 4. Millett DT, Gordon PH. A 5-year clinical review of bond failure with a no-mix adhesive (Right on). Eur J Orthod 1994;16:203 11. 5. Matasa CG. Microbial attack of orthodontic adhesives. Am J Orthod Dentofac Orthop 1995;108:132 41. 6. Freund M, Munksgaard EC. Enzymatic degradation of BISGMA/TEGDMA-polymers causing decreased microhardness and greater wear in vitro. Scand J Dent Res 1990;98:3515. 7. de Gee AJ, Wendt SL, Werner A, Davidson CL. Inuence of enzymes and plaque acids on in vitro wear of dental composites. Biomater 1996;17:1327 32. 8. Larsen IB, Munksgaard EC. Effect of human saliva on surface degradation of composite resins. Scand J Dent Res 1991;99:25461. 9. Larsen IB, Freund M, Munksgaard EC. Change in surface hardness of BisGMA/TEGDMA polymer due to enzymatic action. J Dent Res 1992;71:1851 3. 10. Jensen SB, Loe H, Schiott CR, Theilade E. Experimental gingivitis in man. IV Vancomycin induced changes in bacterial plaque composition as related to development of gingival inammation. J Periodont Res 1968;3:284 93. 11. Liu PV. Extracellular toxins of Pseudomonas aeruginosa. J Infect Dis 1974;130:S94 9.
Structured Abstract
Authors Donker HJ, Frandsen EVG, Melsen B. Objectives To elucidate the basis for the hypothesis of bacterial degradation as a potential cause of bracket loss by examination of debonded brackets for signs of decay and by testing the ability of selected bacterial species to degrade composites. Setting and sample population Department of Orthodontics and Department of Oral Biology, Royal Dental College, University of Aarhus, Aarhus, Denmark. A total of 1056 brackets collected upon debonding. Eighty composite discs incubated with bacteria of ve different bacterial species and 16 control discs incubated without bacteria. Design A retrospective clinical study in combination with an in vitro experiment. Experimental variable Collected brackets were inspected macroscopically and microscopically for signs of decay. Composite discs of two brands were incubated with one of ve different bacterial species for 3 months, or until the bacteria had died. Incubation liquid was either broth or articial, carbon-decient saliva and the liquid was renewed twice weekly or not renewed during the test period. Outcome measure The decay observed on the collected brackets was categorized. The weight change of the different composite discs was compared with the weight change of the control discs by the method of univariate analysis of variance. Results Our results did not support the hypothesis that the composite bonding materials tested were degraded by bacteria to any appreciable extent in vivo or in vitro. Conclusion Bacterial degradation of composite bonding material is not a likely cause of bracket loss. Clinical Orthodontics and Research 4, 2001; 112 118 Copyright Munksgaard 2001, ISSN 1397-5927
118 2Clin Orthod Res 4, 2001/112118
CASE REPORT
S Miyawaki Y Yasuda K Yashiro K Takada
Changes in masticatory jaw movement and muscle activity following surgical orthodontic treatment of an adult skeletal Class III case
Authors affiliations: Shouichi Miyawaki, Department of Orthodontics, Okayama University Dental School, Japan Yoshitaka Yasuda, Kohtaro Yashiro, Kenji Takada, Department of Orthodontics, Faculty of Dentistry, Osaka University, Japan Correspondence to: Shouichi Miyawaki, DDS, PhD Department of Orthodontics Okayama University Dental School 2-5-1 Shikata-Cho 700-8525 Okayama Japan Tel: + 81 86 235 6692 Fax: + 81 86 235 6694 E-mail: smiyawak@dent.okayama-u.ac.jp
Abstract: This case report examines the masticatory jaw movements and electromyograph (EMG) recordings of anterior and posterior temporal and masseter muscles before and after surgical orthodontic treatment in an adult patient with incisor crossbite and skeletal Class III jaw base relationship. The prescribed treatment resulted in a good occlusion and skeletal and dental Class I relationship. The chopping type jaw movement pattern during gum chewing was transformed to more of a grinding motion after treatment. But this motion was not as broad as is normally seen. This observation is indicative of the difculties associated with improving the masticatory jaw movements in an adult patient to a completely normal pattern even after retention. In this patient, the high frequency of silent periods on the EMG that were observed in the early intercuspal phase before treatment were decreased to normal low levels after treatment. A similar decrease was also seen in the mean duration of the chewing cycle. We conjecture that this patient unsuccessfully attempted to compensate for the silent periods by increasing the period of his chewing cycle. Key words: anterior crossbite; Class III; EMG; jaw movement;
Dates: Accepted 22 September 2000 To cite this article: Clin. Orthod. Res. 4, 2001; 119 123 Miyawaki S, Yasuda Y, Yashiro K, Takada K: Changes in masticatory jaw movement and muscle activity following surgical orthodontic treatment of an adult skeletal Class III case Copyright Munksgaard 2001 ISSN 1397-5927
mastication; surgical orthodontic treatment
Introduction
The skeletal Class III relationship with an anterior crossbite (1, 2). occlusal contacts of anterior teeth mostly due to the compensatory is often associated In such positions, are often observed inclinations of the
Miyawaki et al. Jaw movement and EMG
incisor teeth, and the occlusal loading of the anterior teeth along the sagittal plane is the reverse of what is seen in a normal overjet relationship. The nature of the incisor loading could be important because transient stops of jaw-closing muscle activity (silent periods) are known to be often caused by an excessive mechanical stimulus to the anterior teeth (3, 4). An earlier study reported a high incidence of silent periods in the electromyograph (EMG) of the masseter muscle during chewing in children with an incisor crossbite and skeletal Class I relationship. Orthodontic correction of the crossbite, however, led to a decrease in the incidence of silent periods (5). The effects of excessive, reverse-direction, non-axial occlusal forces on masticatory muscle activity of adult patients are largely unknown. We demonstrate here the changes in masticatory jaw movement and muscle activity following surgical orthodontic treatment of an adult skeletal Class III case.
Case summary
A 20-years 1-month-old male patient presented with the chief complaint of crowding of the upper and lower anterior teeth. He had undergone tonsillectomy at the age of 16 years 3 months, but had no history of trauma, TMD, or periodontitis. He showed a concave prole, mandibular prognathism (Fig. 1), skeletal Class III jaw base relationship (ANB=0), a high mandibular plane angle (SN Mp = 47.0), lingual angulation of the lower incisors (FMIA= 69.5), and a large mandibular length (Ar Me =128.8 mm) for a Japanese adult male (1) (Fig. 2). The upper lateral incisors were linguoverted. Upper incisors and the right canine were in crossbite with the lower teeth (Fig. 3). The overjet was 1.0 mm and the molar relationship Class III. Space analysis revealed an arch length discrepancy of 11.4 mm in the upper and 10.6 mm in the lower dentition.
Masticatory jaw movement and muscle activity before treatment
to the thirty-fth stroke simultaneously (6, 7). Silent periods on the EMG were automatically detected by a customized software (8). The mean incidence of masticatory loops with the jaw-opening trajectories located medial to the jaw-closing trajectories, i.e., the medialout type chews (6), before orthodontic treatment was 68%. The mean jaw movement was of a chopping pattern (Fig. 4A), and the mean duration of a chewing cycle was 850 ms at the pre-treatment stage. The incidences of silent periods on the EMG of the AT, PT, and SM muscles were 52, 24, and 33%, respectively. These were considerably higher than those determined for subjects with good occlusion (5). The mean silent period durations for the AT, PT, and SM muscles were 23, 22, and 22 ms, respectively. Silent periods for the AT, PT, and SM muscles at the pre-treatment stage were observed in the early intercuspal phase (Fig. 5A). The jaw positions when the silent periods occurred were between 0.1 and 0.2 mm in the lateral direction, between 0.3 and 0.6 mm in the anteroposterior direction, and between 0.2 and 0.4 mm in the vertical direction. Thus, a premature occlusal contact of the upper right central incisor with its antagonist was suspected to have occurred during chewing.
Recordings of jaw movement and the EMG of the anterior (AT) and posterior (PT) parts of the temporal and supercial masseter (SM) muscles during the chewing of hard chewing gum on the patients habitual chewing side (right side) were made from the sixth
120 2Clin Orthod Res 4, 2001/119123
Fig. 1. Facial photographs. Upper, pre-treatment stage (20 years 1 month); bottom, post-treatment stage (25 years 5 months).
Fig. 2. Intraoral photographs (frontal and lateral view). Upper, pre-treatment stage (20 years 1 month); middle, post-active-treatment stage (23 years 5 months); bottom, post-treatment stage (25 years 5 months). Treatment progress
The patient gave his informed consent for surgical orthodontic treatment 1 year after his initial visit. Pre-surgical orthodontic treatment was initiated with a pre-adjusted edgewise appliance at age 21 years 5 months. The upper rst and lower second pre-mo-
lars were extracted. A sagittal split ramus setback osteotomy was performed at age 22 years 5 months. Genioplasty was also performed. Exactly 1 year later, the orthodontic appliances were removed. Hawley type retainers were worn on the upper and lower dentitions for 2 years; full time for the rst year and then at night for the second. Identical records were taken after a retention period of 2 years.
Fig. 3. Superimposed tracing of cephalogram. Black lines, pre-treatment stage (20 years 1 month); dotted lines, post-treatment stage (25 years 5 months); unit, mm.
Fig. 4. Mean jaw movement patterns during the chewing of hard chewing gum on the right side in the pre-treatment (A, 20 years 1 month) and the post-treatment (B, 25 years 5 months) stages. The CO position was zeroed to the origin. Frontal, frontal view; Lateral, lateral view; gray jaw movement trajectories, opening phase; black trajectories, closing and intercuspal phases; unit, mm.
121
Treatment results Morphological changes
Discussion
Although the chopping jaw movement pattern became more of a grinding pattern after treatment, it did not become a normal broader one as is observed in subjects with good occlusion (6). This demonstrates the difculties in improving the masticatory jaw movement pattern in an adult patient to a completely normal pattern even after a retention period of 2 years. This may be due to the fact that, while the occlusion and skeletal pattern change, soft tissue such as muscle, remains unchanged. The incidences of silent periods in the EMG of jaw-closing muscles that were observed in the early intercuspal phase decreased signicantly after treatment. Furthermore, the patient showed a considerably higher incidence of silent periods before treatment than patients with incisor crossbite, but without skeletal problems (5). These ndings might suggest that, in addition to the reverse-directed force on the anterior teeth, an excessive non-axially directed occlusal force on the teeth contributed to the increase of the incidence of silent periods in jaw-closing muscles. They could also imply that the silent periods occurred as a protective reex to avoid such a force being applied to the anterior teeth during mastication.
The concave facial prole was improved with surgical orthodontic treatment (Fig. 1), and a good interdigitation of teeth was achieved (Fig. 2). Molars and canines were Class I, as well as the skeletal relationships (ANB = 2.5; Fig. 3). The overjet increased from 1.0 to 1.7 mm.
Changes in masticatory jaw movement and muscle activity after treatment
The masticatory jaw movement pattern changed to more of a grinding pattern after a retention period of 2 years, but it did not show a normal broader pattern (Fig. 4B). The incidences of the medial-out type chews (the normal type chews) increased from 68% at the pre-treatment stage to 90% at the post-treatment stage. The mean chewing cycle duration decreased signicantly from 850 ms at the pre-treatment stage to 769 ms at the post-treatment stage. The incidences of silent periods for the AT, PT, and SM muscles (initially 52, 24, and 33%) decreased to 6, 4, and 8%, respectively, i.e., normal levels (5), at the post-treatment stage. Silent periods in the mean EMG of the AT, PT, and SM muscles observed in the early intercuspal phase at the pre-treatment stage had disappeared in the post-treatment stage (Fig. 5B).
Fig. 5. EMG patterns of the ipsilateral anterior and posterior temporal and supercial masseter muscles during the chewing of hard chewing gum on the right side in the pre-treatment (A, 20 years 1 month) and the post-treatment (B, 25 years 5 months) stages. Vertical lines, EMG amplitude (%) normalized by peak amplitude; horizontal lines, normalized time axes; black, mean; gray, SD; black arrows, silent periods; open, opening phase; close, closing phase; intercuspal, intercuspal phase; COout, beginning of jaw-opening phase; MOP, time of maximum jaw-opening during chewing; COin, end of jaw-closing phase; unit, %.
122 2Clin Orthod Res 4, 2001/119123
This patient required a long chewing cycle time before treatment. We consider that he attempted to compensate for the silent periods. But we also consider that this compensation was ineffective, because silent periods were occurring in the early intercuspal phase.
References
1. Susami R. A cephalometric study of dentofacial growth in mandibular prognathism. J Japan Orthod Soc 1967;26:278 311. 2. Takada K, Yasuda Y, Masuda T, Kunisu S, Sakuda M. Dynamic statistics of new patients in the Department of Orthodontics before and after moving of Osaka University Dental Hospital. Osaka-Daigaku-Shigaku-Zasshi 1987;32(2):47787. 3. Hannam AG, Matthews B, Yemm R. The unloading reex in masticatory muscles of man. Arch Oral Biol 1968;13:361 4.
4. Ahlgren J. The silent period in the EMG of the jaw muscles during mastication and its relationship to tooth contact. Acta Odontol Scand 1969;27:219 27. 5. Sohn BW, Miyawaki S, Noguchi H, Takada K. Changes in jaw movement and jaw closing muscle activity following orthodontic correction of incisor crossbite. Amer J Orthod Dentofac Orthoped 1996;112:403 9. 6. Takada K, Miyawaki S, Tatsuta M. The effects of food consistency on jaw movement and posterior temporalis muscle and inferior orbicularis oris muscle activities during chewing in children. Arch Oral Biol 1994;39(9):793 805. 7. Takada K, Yashiro K, Morimoto T. Application of polynomial regression modeling to automatic measurement of periods of EMG activity. J Neurosci Methods 1995;56:43 7. 8. Takada K, Nagata M, Miyawaki S, Kuriyama R, Yasuda Y, Sakuda M. Automatic detection and measurement of EMG silent periods in masticatory muscles during chewing in man. J Electromyograph Clin Neurophysiol 1992;32: 499 505.
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ANNOUNCEMENTS
March 1, 2002
GREEK ORTHODONTIC SOCIETY. INTERNATIONAL CONFERENCE ON ORTHODONTIC JOURNALS. Athens, Greece. This conference aims to bring together all parts involved in the publication of scientic papers in orthodontics or related subjects. Its purpose is to improve the knowledge and understanding of researchers, writers and clinicians concerning high-quality scientific publications. The conference will include lectures, brief presentations and discussion sessions. Topics to be presented and discussed include the following: Perspectives of the editors, authors, readers and publishers. Impact factor, citation index and circulation. Evidence-based orthodontics. Editors and members of the editorial boards of selected international orthodontic journals as well as distinguised academic colleagues will contribute to the program of the meeting. Initial list of speakers includes T.M. Graber, M.L. Jones, R.-R. Miethke, O.C. Tuncay, D.L. Turpin, and R.L. Vanarsdall. All major publishing companies have been invited to actively participate in the conference. For information contact: Greek Orthodontic Society 95 97 Mavromichali Street, GR-11472 Athens, Greece. Fax: +30 1 3615432.
March 23, 2002
GREEK ORTHODONTIC SOCIETY. 7th INTERNATIONAL SYMPOSIUM. Athens, Greece. For information contact: Greek Orthodontic Society 95 97 Mavromichali Street, GR-11472 Athens, Greece. Fax: +30 1 3615432. Website: www.grortho.gr
1242Clin Orthod Res 4, 2001/124

Orthodontics and Craniofacial Research - Volume 4, Issue 2, May 2001

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EDITORIAL

64 2Clin Orthod Res 4, 2001/6364

B Ahmed MS Gilthorpe R Bedi

Key words: ethnicity; IOTN; perceived orthodontic need

Ahmed et al. Orthodontic need amongst multiethnic children

Materials and methods

Ahmed et al. Orthodontic need amongst multiethnic children

Clin Orthod Res 4, 2001/65712

Ahmed et al. Orthodontic need amongst multiethnic children

Yes Do not know

Yes Do not know

Yes Do not know

Yes Do not know

Yes Do not know

Perceived need for braces

Social class (p =0.011) 8 Braces (p =0.070)

Lower class Yes Do not know

Social class (p =0.029) 9 Braces (p =0.020)

Lower class Yes Do not know

68 2Clin Orthod Res 4, 2001/6571

Ahmed et al. Orthodontic need amongst multiethnic children

Ahmed et al. Orthodontic need amongst multiethnic children

Morphological dento-facial differences

Hours of watching television

Ahmed et al. Orthodontic need amongst multiethnic children

Clin Orthod Res 4, 2001/65712

RA Tanzilli RH Tallents RW Katzberg S Kyrkanides ME Moss

sounds; magnetic resonance imaging; temporomandibular joint disorders

Tanzilli et al. TMJ sounds

Materials and methods

Tanzilli et al. TMJ sounds

74 2Clin Orthod Res 4, 2001/7278

Tanzilli et al. TMJ sounds

Clinical exam+ Clinical exam

Tanzilli et al. TMJ sounds

76 2Clin Orthod Res 4, 2001/7278

Tanzilli et al. TMJ sounds

Tanzilli et al. TMJ sounds

78 2Clin Orthod Res 4, 2001/7278

Maxillary expansion: a meta analysis

Schiffman and Tuncay. Maxillary expansion meta analysis

Materials and methods

Clin Orthod Res 4, 2001/86962

Schiffman and Tuncay. Maxillary expansion meta analysis

Table 2. Final studies

165 191 156 195 199 181

Table 3. Coding categories and meta evaluation factors

Prolective 1.5 Alternate Tx 0 Random 2 3150 1.5

88 2Clin Orthod Res 4, 2001/8696

Schiffman and Tuncay. Maxillary expansion meta analysis

Table 4. Meta analysis factor for each study

165 191 156 195 199 181

Schiffman and Tuncay. Maxillary expansion meta analysis

Expansion obtained (weighted)

Expansion remaining (weighted)

Stability with retainer wear

Stability post -retention

90 2Clin Orthod Res 4, 2001/8696

Schiffman and Tuncay. Maxillary expansion meta analysis

Table 6. Selected characteristics of retention studies

Short -term data (less than 1 year)

Long -term data (more than 1 year)

Hyrax Hyrax, quad removable